Presenter Application Name* First Last Email* PhoneCredentialsShort BioTitle of Activity/PresentationLearning OutcomeProvide a detailed outline/description of the content presented per topic addressedMust be evidence-based or based on the best available evidence. A listing of objectives is not sufficient.List additional presentersTeaching Methods/Learner Engagement StrategiesIndicate both the teaching methods and learner engagement strategies to be used.Teaching methodsPlease check all that apply Lecture AV Support Handout Other Teaching methods (other)Learner Engagement StrategiesPlease check all that apply Q&A Dialogue/discussion Self-check/Reflection Case studies/scenarios Problem-based learning Group project Other Learner Engagement Strategies (other)What type of audio-visual support or materials will you need in your room for your session?Laptops will be available in each room. Please e-mail your presentation to the conference planning team by May 1st or bring your presentation on a flash drive. Projector and screen Flip chart and markers Internet access Speakers/sound Other (Please Describe) Other audio-visual support or materialsReference ListWhen listing out references: 1. Use an approved format (APA, MLA, etc). 2. List starting with most recent to oldest. Please check all reference sources that apply. Information available from the following organization/web site (organization must use current available evidence within past 5 years as resource for readers; may be published or unpublished content. EXAMPLES Agency for Healthcare Research and Quality, Center for Disease Control, National Institutes of Health) Information available through peer-reviewed journal/resource (reference should be within past 5 years) Clinical guidelines (EXAMPLE www.guidelines.gov) Expert resource (individual, organization, educational institution) (book, article, web site) Textbook reference Other Reference List - MINIMUM OF THREE REQUIREDReference List 1Reference List 2Reference List 3Additional ReferencesConflict of Interest StatementIn order to offer CNEs, we will need to verify that you do not have any conflicts of interest or if you do we will have to determine if we can offer CNEs for your presentation.1) Do you have a financial relationship with a commercial interest organization*?**Definition of a Commercial Interest Organization-The American Nurses Credentialing Center (ANCC) defines an organization as having a commercial interest (“Commercial Interest Organization”)if it produces, markets, sells or distributes health care goods or services consumed by or used on patients; is owned or operated, in whole or in part, by an organization that produces, markets, sells or distributes health care goods or services consumed by or used on patients; or; advocates for use of the products or services of commercial interest organizations. (*Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 (www.accme.org) - ANCC’s definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition) YES (Additional Screening Required—Move to Q3) NO (No conflict of interest--STOP) 2) Is there a relationship between the products of the commercial interest organization and the topic of the activity?* YES (Potential conflict that requires resolution) NO (No conflict of interest) 3) If the answer to either question above is YES, please describe:
