RequiredFieldSection 

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formsubmissionid
0

formid
16

userid
375545

isMD
No

eventid
0

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Please complete the information below. Required fields are noted with a red asterisk. Scroll down and
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Basic Information

Suffix Last MI First Salutation

seyam Dina

Birth Day Birth Month Other Degree Degree

11 9 -- ?????? ???? -- Other

Profession
Athletic Trainer Allied Dental Professional Advance Practice Nurse (APN)
Dietetic Technician Registered Dentist Counselor
(DTR)
Non-Physician Industry Fellow/Resident

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 Occupational Therapist Nurse Anesthetist (CRNA) Nurse
Pharmacy Technician Pharmacist Optometrist
Physician Associate Physician Physical Therapist
Registered Nurse (RN) Registered Dietitian Psychologist
Student  Social Worker

Title Organization/Company
school

Medical School First Name on Badge

Professional Designations

Maintenance of Certification (MOC)/Continuous Certification (CC)

.Stanford Medicine is pleased to offer MOC/CC credit for some of its activities
Are you board certified by one of the following boards and plan to claim MOC/CC credits if
?offered

American Board of Anesthesia (ABA)

American Board of Internal Medicine (ABIM)
American Board of Orthopedic Surgery (ABOS)
American Board of Otolaryngology – Head and Neck Surgery (ABOHNS)
American Board of Pediatrics (ABP)
American Board of Pathology (ABPath)
American Board of Surgery (ABS)

Yes 
No 

:Please enter your board credentials here

.# If you do not know your ABIM Diplomate ID, please click here to look up your ID
.# If you do not know your ABP Diplomate ID, please click here to look up your ID
.If you do not know your ABA Diplomate ID, please call the ABA Communications Center at (866) 999-7501
.If you do not know your ABPath Diplomate ID, please call the American Board of Pathology at (813) 286-2444

.If you do not know your ABO Diplomate ID, please click here to look up your ID#. or call 610-664-1175

Patient Population

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 :Indicate which patient population you primarily work with
None  Both  Pediatric  Adult 

Stanford Affiliation

Stanford Affiliation
Not affiliated with Stanford Medicine

Department
Biochemistry Anesthesiology Perioperative Anesthesiology
Bioengineering & Pain Medicine
Cardiothoracic Surgery Cardiology Biomedical Data Sciences
Center for Biomedical Ethics, Center for Asian Health Center for Artificial
Medical Humanities & Arts Research and Education Intelligence in Medicine and
Program Imaging (AIMI)
Center for Population Health Center for Immersive and Center for Digital Health
Sciences Simulation-based Learning
Chemical and Systems (CISL)
Biology
Department of Professional Dean's Office Comparative Medicine
Practice Evaluation
Emergency Medicine Developmental Biology Dermatology
Graduate Medical Education Genetics Environmental Health and
Institutes - School of Medicine Health Research and Policies Safety
Medicine - Blood & Marrow Lucile Packard Children's Lane Medical Library
Transplantation Hospital Stanford
Medicine - Center for Primary Medicine - Center for Medicine - Cardiovascular
Care and Outcomes Research Biomedical Informatics Medicine
Medicine - Endocrinology Research
Medicine - Hospice & Medicine - Hematology Medicine - Gastroenterology
Palliative Medicine & Hepatology
Medicine - Infectious Disease Medicine - Immunology & Medicine - Hospital Medicine
Medicine - Internal Medicine Rheumatology
Medicine - Pain Medicine Medicine - Oncology Medicine - Nephrology
Medicine - Stanford Medicine - Pulmonary, Allergy Medicine - Primary Care and
Prevention Research Center & Critical Care Population Health
Molecular and Cellular Microbiology and Immunology Medicine - Value Based Care
Physiology Program
Neurosurgery Neurology Neurobiology
Office of Diversity in Medical Office of Community Obstetrics & Gynecology
Education Engagement
Office of the Chief of Staff Office of the Chief Medical Office of Faculty Development
Ophthalmology Officer & Diversity
Pathology Otolaryngology Orthopaedic Surgery
Psychology Pediatrics

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 Radiology Radiation Oncology Psychiatry and Behavioral
Stanford Center for Clinical Stanford BeWell Sciences
and Translational Research
and Education
Stanford Children's Health Stanford Center for Stanford Center for
Stanford Graduate School of Innovation in Global Health Continuing Medical Education
Business
Stanford Healthcare Service Stanford Health Care Stanford Graduate School of
Excellence Education
Stanford Medicine Center for Stanford Medicine Alliance for Stanford Law School
Health Education Disability Inclusion and Equity
Stanford Medicine Center for (SMADIE)
Improvement
Stanford School of Stanford School of Earth, Stanford Medicine Presence
Engineering Energy & Environmental
Stanford School of Sciences
Humanities and Sciences
Teaching and Mentoring Surgery Structural Biology
Academy
VA Palo Alto Healthcare Urology University Medical Partners
System
Wall Center Pulmonary VPTL - Stanford Center for Vaden Health Center
Vascular Disease Health Education
WellMD & WellPhD

:Affiliation Outside of Stanford

AL-ZOHOUR Secondary girls School

Credentials

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.click the minus (-) sign for that row

ID Credentials (Select One)

State License(s)

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.minus (-) sign for that row

:Expiration Date # License :State License Type

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 Specialty and Subspecialty

Specialties

Specialty

Subspecialty
Option2 Option

:Areas of Interest
Option2 Option

Please Enter Your Primary Address

City Address 1
ismailia EGYPT ,ISMAILIA

Zip/City/Post Code State Address 2

Country Address 3
EGYPT

Phone

Ext Phone Intl Code

1004539264 20+

Mobile
01004539264 20+

Emergency Contact Information

Emergency Contact Number Emergency Contact Name

01004539264 20+ Dina said

Email

Confirm Email Address Email Address

[email protected] [email protected]

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 .Email addresses do not match

It is important that we contact you via our learner database ([email protected])

to provide important information such as activity updates, evaluations, postponements, and
.cancellations
.No, I don’t want to receive important updates  .Yes, I want to receive important updates 

Social Media

LinkedIn Account Twitter Account

Password

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Confirm Password Password

.Passwords do not match

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Administrative Assistant Information

Assistant Phone Assistant Email Assistant Name

Demographic Information (optional)

:Why We Collect This Information

Improve User Experience: By understanding the diverse backgrounds of our users, we can tailor .1
.our services and content to better meet your needs
Enhance Inclusivity: Your responses help us create a more inclusive environment by identifying .2
.and addressing the needs of different demographic groups
Inform Development: Insights gained from demographic data guide our efforts in developing .3
.features and resources that benefit our entire community

Race/ Ethnicity Age Gender

White Under 25 Female

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 Privacy Policy and Attestations

Stanford University cares about the privacy and confidentiality of your information and takes protecting
your privacy very seriously. Our privacy policy is available at https://www.stanford.edu/site/privacy. By
using the SCCME website and participating in a SCCME activity in any manner, you acknowledge that
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Privacy Policy

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.personal data as outlined in this notice

As an ACCME Accredited Provider, we share and transmit your CME/MOC completion data
with the Accreditation Council for Continuing Medical Education (ACCME), licensing board(s),
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Accreditation Council for Continuing Medical Education (ACCME), licensing board(s), and
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