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Kentucky Health Promotion Program Logging
Workshop Location and Type
Host Organization:
*
Intervention:
*
Workshop Dates
Intervention Start Date:
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Intervention End Date:
*
Program Site:
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Course Site Location Name:
Address 1:
*
Address 2:
City:
*
State:
*
Zip:
*
County:
*
Intervention Location Type:
*
If Other:
Workshop Instructors
Group Leader 1 Last Name:
*
Group Leader 1 First Name:
*
Group Leader 1 Employment:

*
Contact Phone Number:
*

Group Leader 2 Last Name:
Group Leader 2 First Name:
Group Leader 2 Employment:

Contact Phone Number:
 
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