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Instructor First Name

Instructor Last Name

Course Date

Discipline

Instructor E-mail Address

Address 1

Address 2

City

State

Postal Code

Country Where Facilitator Lives

Language

Lessons Learned

Teaching Method

Course Conducted

Doctor - Total Number Taught by Discipline

Nurse - Total Number Taught by Discipline

Midwife - Total Number Taught by Discipline

Birth Attendant - Total Number Taught by Discipline

Other - Total Number Taught by Discipline

Doctor - Knowledge Check Number Passed

Nurse - Knowledge Check Number Passed

Midwife - Knowledge Check Number Passed

Birth Attendant - Knowledge Check Number Passed

Other - Knowledge Check Number Passed

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