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You are here: Department of Family Medicine > Faculty > Academic Contributions > Academic Contribution Reporting Form

Academic Contribution Reporting Form

General Information
Learner Information
Please enter as much information as possible so that we may capture your contribution. If we are missing information we will not be able to give credit.
Rotation Setting:

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This form cannot be saved. Once you submit your form and close the window all information will be lost.

Please print the form once you are taken to the 'Thank You' page if you wish to have a copy for yourself.