Physician Name (First Last)
Email (only add if you would like to receive a copy of this submission, otherwise skip)
Date (Activity 1)
-
Month
-
Day
Year
Entry 1
Hours Spent (Activity 1)
Entry 1
Select TVU Category (Activity 1)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 1
Description of Services (Activity 1)
Entry 1
Date (Activity 2)
-
Month
-
Day
Year
Entry 2
Hours Spent (Activity 2)
Entry 2
Select TVU Category (Activity 2)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 2
Description of Services (Activity 2)
Entry 2
Date (Activity 3)
-
Month
-
Day
Year
Entry 3
Hours Spent (Activity 3)
Entry 3
Select TVU Category (Activity 3)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 3
Description of Services (Activity 3)
Entry 3
Date (Activity 4)
-
Month
-
Day
Year
Entry 4
Hours Spent (Activity 4)
Entry 4
Select TVU Category (Activity 4)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 4
Description of Services (Activity 4)
Entry 4
Date (Activity 5)
-
Month
-
Day
Year
Entry 5
Hours Spent (Activity 5)
Entry 5
Select TVU Category (Activity 5)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 5
Description of Services (Activity 5)
Entry 5
Date (Activity 6)
-
Month
-
Day
Year
Entry 6
Hours Spent (Activity 6)
Entry 6
Select TVU Category (Activity 6)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 6
Description of Services (Activity 6)
Entry 6
Date (Activity 7)
-
Month
-
Day
Year
Entry 7
Hours Spent (Activity 7)
Entry 7
Select TVU Category (Activity 7)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 7
Description of Services (Activity 7)
Entry 7
Date (Activity 8)
-
Month
-
Day
Year
Entry 8
Hours Spent (Activity 8)
Entry 8
Select TVU Category (Activity 8)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 8
Description of Services (Activity 8)
Entry 8
Date (Activity 9)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 9)
Entry 9
Select TVU Category (Activity 9)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 9)
Entry 9
Date (Activity 10)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 10)
Entry 9
Select TVU Category (Activity 10)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 10)
Entry 9
Date (Activity 11)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 11)
Entry 9
Select TVU Category (Activity 11)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 11)
Entry 9
Date (Activity 12)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 12)
Entry 9
Select TVU Category (Activity 12)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 12)
Entry 9
Date (Activity 13)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 13)
Entry 9
Select TVU Category (Activity 13)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 13)
Entry 9
Date (Activity 14)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 14)
Entry 9
Select TVU Category (Activity 14)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 14)
Entry 9
Date (Activity 15)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 15)
Entry 9
Select TVU Category (Activity 15)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 15)
Entry 9
Date (Activity 16)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 16)
Entry 9
Select TVU Category (Activity 16)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 16)
Entry 9
Date (Activity 17)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 17)
Entry 9
Select TVU Category (Activity 17)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 17)
Entry 9
Date (Activity 18)
-
Month
-
Day
Year
Entry 9
Hours Spent (Activity 18)
Entry 9
Select TVU Category (Activity 18)
Please Select
CT Programmatic Support :
Cardio Neuro :
Refractory Hypertension Program :
IAH Programmatic Development :
ILH Programmatic Development :
IFOH Programmatic Development :
Fellowship Program Support :
Research Collaborative Support :
CICU Teaching :
Outreach / CME / Dinner Meetings :
APP :
Participation in INOVA CME :
Imaging full day reading :
Imaging half day reading :
Other :
Entry 9
Description of Services (Activity 18)
Entry 9
Cost Center
1100-20004
GL Code
665011
Total Hours
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