Step IV – Optional Professional Development Workshops* (Limit 100 Per Session)
Step X– Demographic Information
Member & Non-Member
A. How many times have you attended the APIC Annual
Conference?
*Must be registered for the full conference to attend Free
a.  This is my first time b.  2-4 times
5. Pediatric Infectious Diseases: Monday June 8
c.  5-7 times d.  Over 8 times
Implementing Prevention Measures 1:30pm – 4:00pm
 Will Attend
Monday June 8
B. How long have you been an APIC member?
6. Long-Term Care 1:30pm – 4:00pm
 Will Attend
a.  Just Joined b.  1-3 years
7. The Elevator Speech and Other Tools for Recruiting Monday June 8 c.  4-6 years d.  6-9 years
Initiative Support 1:30pm – 4:00pm
 Will Attend
e.  10+ years f.  Not a member
Tuesday, June 9
8. Surveillance Definitions 2:45pm – 4:00pm
 Will Attend C. Professional Status
Tuesday, June 9
a.  Administrator/COO
9. Study Design 2:45pm – 4:00pm
 Will Attend
b.  CMO
10. Risk Assessment for Infection Prevention and Wednesday, June 10
c.  CNO
Control Programs 1:30pm – 4:00pm
 Will Attend
d.  Dentist
Wednesday, June 10
e.  Employee Health
11. You too, Can Write an Abstract 1:30 pm - 5:00 pm
 Will Attend
f.  EMT/Emergency Preparedness Agency
Total Step IV $ 0.00
g.  Engineer/Architect
h.  Epidemiologist
i.  Infectious Disease MD
Step V – Optional Orientation Sessions* (Limit 75 per Session)
j.  LPN/LVN
Sunday, June 7 *Must be registered for the full conference to attend Member & Non-Member
k.  Medical Doctor (MD
l.  Medical Technologist
Check box if you will attend FREE
m.  Microbiologist
12. Conference Survival 101 3:30pm - 4:30pm  Will Attend
n.  Nurse Practitioner
13. International Attendees Conference Orientation 3:30pm - 4:30pm  Will Attend o.  Public Health
Total Step V $ 0.00
p.  PharmD
q.  Quality/Process Improvement
r.  Researcher
Step VI – Optional Poster Rounds with Professor (Limit 12 per round)
s.  RN
14. Poster Rounds with Tuesday, June 9 Cost: $10 Donation to the APIC Research Foundation, A
t.  Risk Manager
Professor 10:30 AM - 11:30 AM Division of APIC. One ticket per person.
u.  Safety Officer
Total Step VI $ v.  Surgeon
w.  Other ______________________
Step VII – Optional Meet-the-Expert Sessions (Limit 25 per session)
D. Practice Setting
Wednesday, June 10 Member & Non-Member Early/Regular
a.  Acute Care Inpatient/Outpatient
Program/Services
Morning Sessions Afternoon Sessions $65 per Session b.  Ambulatory Care
15. IC Issues in Small Hospitals  6:45 – 7:45am 19. IC Issues in Small Hospitals  12 – 1:00pm
c.  Behavioral Health
16. Investigating Clusters of 20. Investigating Clusters of
d.  Correction/Detention
Outbreaks  6:45 – 7:45am Outbreaks  12 – 1:00pm e.  Dialysis Center
17. Technology to Reduce Device 21. Technology to Reduce f.  Disaster/Emergency Preparedness
Infections  6:45 – 7:45am Device Infections  12 – 1:00pm
g.  EMS/First Responder
18. IC Issues in the OR  6:45 – 7:45am 22. IC Issues in the OR  12 – 1:00pm
h.  Home Care
( ___# of Sessions x $65 each =$___ ) Total Step VII $
i.  Hospital Based Clinic
j.  Long-term Care
k.  Military
Step VIII - TOTAL FEES Member Early/Regular Non-Member Early/Regular
l.  Pediatrics
Total Step I $ m.  Physician
n.  Public Health, Community Health
Total Step II $
o.  Self-Employed
Total Step III $ p.  Surgery Center
q.  University/School
Total Step IV $
r.  Veteran’s Affairs
Total Step V $ s.  Other
Total Step VI $
E. Highest Educational Level
a.  1 year technical b.  Diploma
Total Step VII $
c.  Associate Degree d.  Bachelor’s
GRAND TOTAL ALL FEES (ADD STEPS I - VII) $ $
e.  Master’s f.  PhD
g.  MD
Step IX – Payment Information
F. Years in Infection Control
a.  Less than 1 b.  1-3
 Enclosed is my check for $ ____________________ payable to APIC (See Grand Total All Fees above).
c.  4-9 d.  10 or more
Checks will be processed electronically. If you do not want your check converted electronically, please select
G. Are you CIC certified?
another method of payment such as by credit card.
a.  Yes b.  No
 Please charge my credit card: (check one)  AMEX  VISA  MasterCard
Billing Address: (required – must match card billing address)
Card# Exp. Date
__________________________________________
Name on card (print)
__________________________________________
Signature – your signature authorizes your credit card to be charged for the total payment due. APIC reserves
the right to charge the correct amount if different from the total listed. __________________________________________
APIC 2009, Ft. Lauderdale, FL, June 7-11 27
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