AF IMT Form 1541 Credentials Continuing Health Education Training Record

AF IMT Form 1541 is a U.S. Air Force IMT (Information Management Tool) form also known as the "Credentials Continuing Health Education Training Record". The latest edition of the form was released in July 1, 1982 and is available for digital filing.

Download a PDF version of the AF IMT Form 1541 down below or find it on U.S. Air Force IMT (Information Management Tool) Forms website.

ADVERTISEMENT
CREDENTIALS CONTINUING HEALTH EDUCATION TRAINING RECORD
AUTHORITY: 10 U.S.C. 8112 and EO 9397
PURPOSE: To provide a record of an individual's participation in continuing health education activities.
ROUTINE USE: Used by individual practitioners to report personal continuing education accomplishments. SSAN is used for positive
identification of individual and records.
DISCLOSURE IS VOLUNTARY: However, failure to provide information may preclude awarding clinical privileges.
I.
IDENTIFICATION
NAME (Last, First, Middle Initial)
GRADE
SSAN
CORPS
DUTY ADDRESS (PENCIL ONLY)
SPECIALTY
PAFSC
2AFSC
I
ACTIVITIES (Conferences, Seminars, Meetings, Lectures, Publications, etc.)
I
.
(self-instruction, consultation, self-assessment, etc.)
DESCRIPTION OF ACTIVITY
CREDIT
NAME OF
NUMBER OF
LOCATION
CATEGORY
(Title of course, meeting, lecture, paper,
DATES
SPONSOR
CREDIT HOURS
self-instruction, etc.)
(1 - 5)
AF IMT 1541, JUL 82, V1
CREDENTIALS CONTINUING HEALTH EDUCATION TRAINING RECORD
AUTHORITY: 10 U.S.C. 8112 and EO 9397
PURPOSE: To provide a record of an individual's participation in continuing health education activities.
ROUTINE USE: Used by individual practitioners to report personal continuing education accomplishments. SSAN is used for positive
identification of individual and records.
DISCLOSURE IS VOLUNTARY: However, failure to provide information may preclude awarding clinical privileges.
I.
IDENTIFICATION
NAME (Last, First, Middle Initial)
GRADE
SSAN
CORPS
DUTY ADDRESS (PENCIL ONLY)
SPECIALTY
PAFSC
2AFSC
I
ACTIVITIES (Conferences, Seminars, Meetings, Lectures, Publications, etc.)
I
.
(self-instruction, consultation, self-assessment, etc.)
DESCRIPTION OF ACTIVITY
CREDIT
NAME OF
NUMBER OF
LOCATION
CATEGORY
(Title of course, meeting, lecture, paper,
DATES
SPONSOR
CREDIT HOURS
self-instruction, etc.)
(1 - 5)
AF IMT 1541, JUL 82, V1
DESCRIPTION OF ACTIVITY
CREDIT
NAME OF
INCLUSIVE
NUMBER OF
CATEGORY
(Title of course, meeting, lecture, paper,
LOCATION
SPONSOR
DATES
CREDIT HOURS
(1 - 5)
self-instruction, etc,)
III.
CARDIOPULMONARY RESUSCITATION TRAINING (DATES)
INITIALS OF
ADVANCED CARDIAC
ADVANCED TRAUMA
BASIC LIFE SUPPORT
REFRESHER TRAINING
VERIFYING
LIFE SUPPORT
LIFE SUPPORT
OFFICIAL
(V1)

Download AF IMT Form 1541 Credentials Continuing Health Education Training Record

979 times
Rate
4.7(4.7 / 5) 49 votes
ADVERTISEMENT
Page of 2