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PSHA Webinar Event Submission Form
If you are human, leave this field blank.
Contact Information for PSHA Office
Contact Name
*
Email
*
Phone
*
Webinar Information
Date of Event
*
Event Start Time
*
Event End Time
*
Event Title
*
Abstract
*
Information Level (select one):
*
Introductory
Intermediate
Advanced
Content Area (select one):
*
For assistance, refer to
https://www.asha.org/ce/understanding-continuing-education-terminology/
Related
Professional
Learning Objectives (Provide 3 outcomes):
For assistance, refer to
http://2015.attendicec.org/wp-content/uploads/2015/02/ICEC.2015.USF-WritingGoodObjectives.pdf
Outcome 1
*
Outcome 2
*
Outcome 3
*
Time-Ordered Agenda
*
Please provide detail on the sessions schedule by time period. Example:
5-Minutes – Introduction
25-Minutes – Case Studies
15-Minutes – Resources
15-Minutes – Question and Answer
Special Classification (If applicable):
DEI
Ethics
Supervision
Presenter Information
Presenter #1 - Name
*
Presenter #1 - Credentials
*
Presenter #1 - Affiliation
*
Presenter #1 - Bio
*
#1 Financial Disclosures:
This presenter has relevant financial relationships to disclose:
Please explain:
#1 Non-Financial Disclosures:
This presenter has relevant non-financial relationships to disclose:
Please explain:
Presenter #2 - Name
Presenter #2 - Credentials
Presenter #2 - Affiliation
Presenter #2 - Bio
#2 Financial Disclosures:
This presenter has relevant financial relationships to disclose:
Please explain:
#2 Non-Financial Disclosures:
This presenter has relevant non-financial relationships to disclose:
Please explain:
Presenter #3 - Name
Presenter #3 - Credentials
Presenter #3 - Affiliation
Presenter #3 - Bio
#3 Financial Disclosures:
This presenter has relevant financial relationships to disclose:
Please explain:
#3 Non-Financial Disclosures:
This presenter has relevant non-financial relationships to disclose:
Please explain:
Presenter #4 - Name
Presenter #4 - Credentials
Presenter #4 - Affiliation
Presenter #4 - Bio
#4 Financial Disclosures:
This presenter has relevant financial relationships to disclose:
Please explain:
#4 Non-Financial Disclosures:
This presenter has relevant non-financial relationships to disclose:
Please explain:
Presenter #5 - Name
Presenter #5 - Credentials
Presenter #5 - Affiliation
Presenter #5 - Bio
#5 Financial Disclosures:
This presenter has relevant financial relationships to disclose:
Please explain:
#5 Non-Financial Disclosures:
This presenter has relevant non-financial relationships to disclose:
Please explain:
Do you agree to have your presentation recorded:
*
YES
NO
Briefly explain why this information is important to the field (this will be used for our social media posts):
Include profile name or URL for social media sharing, if applicable:
Facebook:
Instagram:
Linked In:
Photo Use Permission
*
PSHA advertises upcoming events across a variety of platforms, including email, web publications, and social media. If we can use your photo and/or profile to be used for event marketing, please indicate your consent below.
I hereby grant permission to PSHA to use the attached photo in print/web publications, including PSHA website, email marketing and social media.
I hereby grant permission to PSHA to identify me using the below social meds tags/profiles for posts that include my photo/presentation info.
Please upload a headshot:
Please only upload, jpeg,or png files.
Submit