Preparedness Symposium Speaker Packet
You can download this document for future reference
Session Title
*
Session Description
*
Learning Objective #1
*
.
Learning Objective #2
.
Learning Objective #3
.
Speaker Information
The registration fee for the Preparedness Coalition Symposium will be complimentary for the appointed speaker. Should the application be submitted on behalf of a panel, the registration fee for the second presenter will also be exempted. Please note that a maximum of two speakers will be permitted to present. It is mandatory for each speaker on a panel to complete the requisite speaker packet. Upon selection, we will facilitate your registration as a speaker. It is important to note that all speakers will bear the responsibility for their own accommodation and travel costs.
Lead Presenter Information:
*
First Name
Last Name
*
Organization
*
Title/ Credentials
*
Email
*
Phone number
Lead Presenter Bio Upload (or type below
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Lead Presenter Bio (or upload above)
Co-Presenter Information:
First Name
Last Name
Organization
Title/ Credentials
Email
Phone number
Co-Presenter Bio Upload (or type below
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Co-Presenter Bio (or upload above)
AV Requirements
Breakout session rooms will contain one of each of the following items for use during presentations.
Laptop
Projector
Screen
Presentation Remote
Microphone
If additional or special items are needed for your session, include your audiovisual requirements in the form below. Please be as specific as possible so that the Symposium staff may be better able to meet your request. Keep in mind that if you have multiple presenters in your session, you should consider requesting additional equipment.
I request that additional AV equipment be provided for my session (list requested items)
Back
Next
Name of Individual (with credentials)
*
Title of NCPD Activity
Date and Location of Education
Individual’s prospective role(s) in NCPD activity: Identify the prospective role(s) that this person may have in the planning and delivery of this education (choose all that apply)
Nurse Planner
Content Expert
Teacher, Instructor, Faculty
Author, Writer
Reviewer
Enter the name of the Ineligible Company
Enter the Nature of Financial Relationship
Has the Relationship Ended (last 24 months)
1
2
3
4
5
6
Date
*
-
Month
-
Day
Year
Date
Back
Next
Name of Individual (with credentials)
*
Title of NCPD Activity
Date and Location of Education
Individual’s prospective role(s) in NCPD activity: Identify the prospective role(s) that this person may have in the planning and delivery of this education (choose all that apply)
Nurse Planner
Content Expert
Teacher, Instructor, Faculty
Author, Writer
Reviewer
Enter the name of the Ineligible Company
Enter the Nature of Financial Relationship
Has the Relationship Ended (last 24 months)
1
2
3
4
5
6
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: