Summary of revisions made June 2010
Program Submission Worksheet Important: Review the General Policies for Presenters before proceeding.The deadline for program submissions is August 22, 2016.To submit a proposal:Compile your program and primary presenter bio and disclosure in this worksheet. You will cut and paste this information to the online form in step 3.If applicable, complete a separate Co-Presenter Bio and Disclosure Form [MSWord] for each co-presenter and save under a file name beginning with the co-presenter's LAST NAME. You will attach these forms to the online form in step 3.Once you are sure all information is complete and can be entered online in one sitting, cut and paste the information from this worksheet into the Online Program Submission Form. At the end of the online form, you will be asked to attach your Co-Presenter Bio and Disclosure forms. (Please attach MSWord documents, not pdf files.)Required fields are indicated by an asterisk “*”. Retain this worksheet and your co-presenter forms for future reference.Program Information* Program Title: The title of the proposed program should reflect the content of that program. While cute titles may sound clever, they tend to detract from the professionalism of the conference and make it harder to determine what will be presented.* Type of Submission (Choose one)Description of Types of SubmissionsChoose the time length most appropriate for your session’s topic, objectives, and content. The length of the session does not reflect on its potential quality and likelihood for selection. Note that we may not be able to accommodate your preference.__ 3-hour Pre-Conference Workshop __ 60-minute General Session __ 90-minute General Session __ I can adjust my general session for either 60 or 90 minutes* Abstract: Provide a short (75 words), descriptive abstract of your presentation that will be inserted VERBATIM in conference materials. Please be concise and clear with your description. If your presentation will address original research, please specify.Does your program address diversity? If so, describe how it addresses diversity based on the following aspects: age; gender identity, including transgender; marital status; physical size; psychological/physical/ learning disability; race/ethnicity; religious, spiritual, or cultural identify; sex; sexual orientation; socioeconomic status; military veteran status. (Not a prerequisite for program selection.)* Will your presentation include content related to pharmacology? If yes, please ensure that your objectives and content (below) validate the pharmacology component. ___ Yes ___ NoIf yes, please estimate the percentage of session content related to pharmacology, according to the selections to the right. ___ 10% ___ 30% ___ 50% ___ 75% ___ 100%* Audience:Who is the expected learner for your program?Note: The Continuing Education Committee uses this information to help determine CE credit for the program. Select all that apply.__ Administrator __ Health Information Management Professional__ Physician__ Advanced Practice Clinician __ Mental Health Professional__ Psychiatrist__ Dietitian/Nutritionist__ Nurse__ Student__ Health Educator__ Pharmacist__ Other:* Practice Gap: When there is a gap between what the professional is currently doing or accomplishing compared to what is desired/achievable on the basis of current professional knowledge, there is a professional practice gap. The goal of a strong educational session is to change participants’ knowledge, skill, or performance in an effort to eliminate the practice gap – ultimately making a positive change in student health outcomes. With this in mind, complete the following questions so that program planners have a clear understanding of how the information presented in your session will change participants’ knowledge, skills, or performance.Briefly describe the practice gap related to your session topic.* Type of Gap: This presentation will address a gap in:___ Knowledge (participants don’t know what they need to do)___ Skill (participants know what to do but lack the tools or strategies to implement it) ___ Both* Description of current state (e.g., Smoking is allowed on campus as long as it isn’t within 25 feet of any building.)* Description of desired/achievable state (e.g., Tobacco-free campus)* Learning Outcome (Describe what the learner will be able to do as a result of participating in the educational session.)Learning Objectives and ContentImportant: Refer to the Instructions for Writing Learning Objectives and Content before completing this section.Each Learning Objective should complete the phrase, "After this session, attendees should be able to..."Begin each objective with one of the following measurable verbs: Describe, Explain, Identify, Discuss, Compare, Define, Differentiate, List.End each sentence with a period.Make a separate objective for each action. Example: Define sleep deprivation and the consequences. These are two separate actions and should be split into two objectives as follows:1. Define sleep deprivation.2. List the consequences of sleep deprivation.Note: If the presentation will address mental health issues, please ensure this is reflected in the learning objectives.Content is the information needed to meet each learning objective.Objective: Define sleep deprivation.Content: degrees of sleep, quantity of sleep, quality of sleep, circadian factorsLearning Objective 2-3 learning objectives are recommended for a 60- or 90-minute sessionAfter this session, attendees should be able to:ContentList specifics that will be covered under each objective. Content must:Be in the form of a brief list, separated by commasBe congruent with purpose and objectivesInclude details beyond a restatement of objectivesReflect the intent of the objectivesBe evidence-based or based on the best available evidenceLength (i.e., 25%, 30%, 50%)Presenter(s)List all presenters who may contribute to this objective.Learning Method (i.e., lecture and Q&A, group discussion, role play)1.2.3.4.Content can be based on:Information available from organizations’ website(s) (organization must use current available evidence; may be published or unpublished content; examples: Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, National Institutes of Health)Peer-reviewed journal(s)/resource(s)Clinical guidelines, public health practice guidelines (example: )Expert resource(s) (example: individual or educational institution’s book, article, website)TextbooksBest practices or new and emerging issues(If applicable, provide specific website address, journal volume number, etc., so that the data can be easily accessed by program planners.)* Content for this educational activity was based on: Primary Presenter Bio and Disclosure FormACHA will generally* not accept, approve, or include in its annual meeting program any presentation in which the presenter(s) has a direct financial relationship with any for-profit business entity, and the presentation topic is directly related to the business entity, or its products and services. All disclosures that are determined by the ACHA Program Planning Committee Chair to be relevant relationships will be shared with the participants/learners in meeting materials and prior to the start of the educational activity.* See ACHA General Policies for PresentersACHA 2017 Annual MeetingPresenter, Speaker, Discussant, Respondent, Faculty COI/Disclosure Form.Please read the ACHA General Policies for Presenters, the APHA Conflict of Interest Policy; the ANCC Continuing Education Content Integrity Standards, and the ACCME Commercial and Sponsorship Support Standards (links at bottom of form).Session Title:Name:List your completed academic degree(s), institution where the degree was earned, and major or specialty area. (e.g., PhD, ABC University, clinical psychology)DegreeInstitutionMajor or Specialty AreaList any current certifications (e.g., CHES, APN, LPC)Institution/Employer:Address:Job Title:City/State/Zip:Phone:Email:List your publications that are most relevant to the proposed topic (up to 10).Biographical Qualification Statement: (Example: I have been the principal or co-principal of multiple federally funded grants focusing on the epidemiology of drug abuse, HIV prevention and co-occurring mental and drug use disorders. Among my scientific interests has been the development of strategies for preventing HIV and STDs in out-of-treatment drug users.)I am qualified to give this specific presentation because…Bio statement must state content expertise. Please submit your biographical qualification statement below. Also include any relevant academic appointments, involvement in professional organizations, and/or awards/honors received. Limit 75 words.Conflict of Interest (COI) Disclosure - ResolutionA CE worthy educational activity/session must be developed and presented with independence, objectivity and scientific rigor, free from promotion of specific goods or services, or bias. A Conflict of Interest (COI) is present if any relationship of a financial nature exists that would potentially bias the planner, program reviewer presenter, speaker, discussant, respondent, faculty because they may have an impact on the content of an educational activity.Such a relationship may be:with a commercial entity, or entity controlled/owned by an entity that produces, markets, re-sells, or distributes healthcare goods or services that are consumed by, or used on, patients/clients. Pharmaceutical or biomedical device entities whose goods or services are related to therapeutic areas are such commercial entities. Additional entities include those that develop, produce, market, or distribute products and services that promote wellness, and for-profit entities that provide administrative products and/or services used in student health.A salary; consulting fee; honoraria; ownership interest except diversified mutual funds; private research or program contracts or grants; publications; royalties; membership on advisory or top level boards or panels that give remuneration. Exempt entities that are not considered commercial entities for CE purposes are non-profits, governments, and non-healthcare related companies. To award CE credits, a COI must be disclosed and resolved before presentation. Each presenter, speaker, discussant, respondent, faculty must agree not to promote the sale of goods or services, or insert bias when presenting the activity/session. Required Disclosure: During the past 12 months have you, or your spouse or partner had a financial, professional or personal relationship (including self-employment and sole proprietorship) that might potentially bias and/or impact content of the educational activity/session: ___ Yes ___ No If yes, list company (s) with relationship:RelationshipName of Commercial Company Resolution: I agree not to promote any products, goods or services or to bias the educational, planning and selection of presenters and to protect the integrity of the content according to the ACHA General Policies for Presenters, APHA Conflict of Interest Policy, the ANCC Continuing Education Content Integrity Standards, and the ACCME Commercial and Sponsorship Support Standards.Sign:Date:(Electronic/typed signatures are acceptable.) ................
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