1. Corrections Connections:
Forming Partnerships to Stop TB
Registration Form
For your convenience, Corrections Connections is being held on three dates. Please check the date you wish to attend:
Thursday, April 26, 2007
 Friday, April 27, 2007
 Friday, May 11, 2007
Last name__________________________ First__________________________
Credentials (MD, RN, etc.)__________________________________________
Facility__________________________________________________________
Address__________________________________________________________
__________________________________________________________
Daytime phone____________________________________________________
____________________________________________________________
Continuing Education Credit Requested:
 Continuing Medical Education  Continuing Nursing Education
Please mail or fax this registration form by Friday, April 13, 2007 to:
Denise Lancto
Division of TB Prevention & Control
305 South Street
Jamaica Plain, MA 02130
Fax: (617)
Presented by: MA Department of Public Health Bureau of Communicable Disease Division of TB Prevention & Control • MA Department of Correction • County Correctional Healthcare Administrators Group • UMass Correctional Health Program. Centers for Disease Control and Prevention • Northeast Regional Training and Medical Consultation Consortium