Speaker Name *

Email Address *

Required entries with every submission*

In accordance with ACCME Planning Policies, please identify the following in relation to your presentation topic(s):

Best Practice - A best practice may be from a national guideline or consensus statement from a credible organization, from peer-reviewed medical literature where more than one source agree on the practice, or from the considered opinion of the expert-planner in the case when no published guideline exists. This becomes the end-goal for your presentation(s).

Current Practice - You can determine this based on interviews (formal or informal) with members of the target audience, a questionnaire, or a published article that reports on findings from learners. THE KEY IS TO GO BEYOND EXPERT PERCEPTION OF THE GAP AND TO INCLUDE THE PERCEPTION OF THE LEARNER.

Gap - This resulting gap is based on the difference between best practice and current practice. Indicate the type of gap (please check all that apply):

Learners lacked knowledge (K)

Learners lacked competence (C)

Learners couldn't implement in practice or performance (P)

Objectives - The GNS Education Committee has provided you with basic objectives for the topic(s) that you will be presenting. As an expert in the field however, please expand upon the provided objectives by completing this form. Objectives should include a verb that is chosen to describe something a physician will do in practice (and not what the teacher will teach). For example, do not use verbs such as “discuss” or “describe, learn or understand.” Use words such as “apply, develop a strategy to…, etc.” Ensure that the objective clearly states a standard against which one can judge the success in achieving the objective. You must provide objectives for each talk.

Title of Presentation 1: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

Example: administer ABC procedure so that patients see a decrease in ABC symptom

1)

2)

3)

Question - Please submit a multiple-choice question to test attendees' knowledge or competency of each topic pre- and post- presentation(s). Your question should be straightforward; no trick questions please!

Question 1:

Answers - Please enter 1 answer per line

A:

B:

C:

D:

E:

Correct answer:

In an effort to focus our funding efforts, please assist us by listing companies that might find your topic(s) of interest and might want to support the meeting financially:

If you have more than 1 topic, please continue with objectives and questions for presentations 2 and 3.

Title of Presentation 2: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

Question 2 :

Answers - Please enter 1 answer per line

A:

B:

C:

D:

E:

Correct answer:

Title of Presentation 3: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

Question 3 :

Answers - Please enter 1 answer per line

A:

B:

C:

D:

E:

Correct answer:

AUDIO VISUAL REQUIREMENTS - I will need the following equipment for my presentation(s):

LCD Projector/Wireless Remote/Laser Pointer

One 35mm slide projector

Two 35mm slide projectors

Video Player - 1/2" tape

Video Player - 3/4" tape

Overhead Projector

Whiteboard and markers, colors:

Flip chart and markers, colors:

Other AV needed:

I require only voice amplification OR  my presentation(s) will include sound beyond my oration.

I will be presenting via Microsoft Power Point and have NO integrated video in my presentation(s) (a laptop will be provided)

I will be presenting via Apple Keynote or other software (speaker must provide laptop to run onsite)

I have integrated video into my presentation file (speaker must provide laptop to run onsite)

HANDOUTS

It is highly encouraged that you supplement your presentation slides with supporting documents, articles, research results, etc.  We must have your handouts by the date above so that we have ample time to prepare the attendee curriculum packets in which your handouts will be inserted. 

I will mail a CD of my handouts to GNS - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092.

I will email my handouts by deadline above to amber@theassociationcompany.com

FINAL PRESENTATION

If you are using Microsoft Power Point and your presentation has NO integrated video, please mail us a copy of your final presentation(s) on CD ahead of the meeting.  Allowing the AV technician to have the presentations pre-loaded on our laptop ensures fewer delays and the meeting running on time.

I will mail a CD of my final presentation(s) to GNS - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092

I will email my presentation(s) by deadline above to amber@theassociationcompany.com