Monuments and Milestones in Nursing Informatics Practice April 18-19, 2008 Gaylord National Resort & Convention Center on the Potomac 204 Waterfront Street National Harbor, MD 20745

 

1.  This information is collected for the purpose of continuing education requirements ~ please fill it out completely, including the objectives.
2.  Each accepted speaker(s) must fill this form by March 1, 2008   Questions - email speaker@ania.org
Speaker Contact Information:
Primary Speaker
Title	Select Prof. Dr. Mr. Mrs. Ms. Other
First name*
Last name*
Academic/Professional Credentials*
Job Title*
Organization*
Work Street Address*
City*	State Abbrev*         Postal code*        Country (if other than US)
Home Street Address*
City*	State Abbrev*          Postal code*         Country (if other than US)
Primary Email Address*
Home Phone* (include Area code)
Cell Phone (include Area code)
Work Phone (include area code)

a.  Co-Author #1 Information	Fill out only if there is a co-author If there is more than one co-author, please include the information below on a separate word document (name the document the title of your presentation and mail to: speaker@ania.org.
Title	Select Prof. Dr. Mr. Mrs. Ms. Other
First name
Last name
Academic/Professional Credentials
Job Title
Organization
a. Work Street Address
City	State         Postal code        Country (if other than US)
b. Home Street Address
City	State         Postal code         Country (if other than US)
c.  Primary Email Address
d.  Home Phone (include area code)

Education Information (basic preparation through highest degree held)
Degree/Yr/Major/Institution
Degree/Yr/Major/Institution
Degree/Yr/Major/Institution
Degree/Yr/Major/Institution
Degree/Yr/Major/Institution
Professional Information	Briefly describe your professional experience/areas of expertise (including publications, presentations                                      and/or planning CE activities) that contribute to your particular involvement with this educational activity.
Learner Objectives	The outline should correspond to the learner objectives.  The outline description does not need to be detailed.  Major topics and subtopics will be sufficient.  Please fill out at least (2) of the objectives If you have more objectives, you may fill it in Presentations are 50 minutes
a.  Objectives:  List objectives in operational/behavioral terms     b.  Content: List each topic area to be covered & provide an outline of the content to be presented     c.  Teaching Method(s):  Describe the teaching method(s)     d.  Time Frame:  State the time frame for the topic area     e.  Examples:  here	1. Objective: 1. Content: 1. Teaching Method(s): 1. Time Frame: 2. Objective: 2. Content: 2. Teaching Method(s): 2. Time Frame: 3. Objective: 3. Content: 3. Teaching Method(s): 3. Time Frame: 4. Objective: 4. Content: 4. Teaching Method(s): 4. Time Frame:
Speaker Release	Name
	Presentation Title
	Permission to copy handouts & record session:  I grant permission to ANIA/CARING and assign the right to reproduce my image, AV materials, printed materials and/or my voice recording in connection with the ANIA/CARING Conference, April 18-19, 2008 in National Harbor, MD in any format, including, but not limited to books, slides, film, filmstrips, video and audio tapes/CD, electronic media, internet, overhead transparencies, and programmed instruction materials.  This permission should be for all rights, including sub assignment, as well as but not limited to advertising, radio, motion picture, television, theatrical and non-theatrical uses through the world.   Guidelines for Presentation:  ANIA/CARING plans to reproduce and collate all presentations from faculties into a professional-appearing Compact Disc.  Presentations must be done in Powerpoint© If you are using copyrighted materials as handout, you must enclose written permission from the holder of the copyright granting permission without obtaining proof of such permission from you in advance of copying.  Any fees associated with obtaining copyright permission is the responsibility of the presenter. If any violation or infringement of personal or property interest (including a copyright or trademark) of any individual or entity in giving this license to ANIA & CARING agree to indemnify AMSN against any and all liability for payment of claims, judgments, or settlements for violation or infringement of any personal or property rights resulting from ANIA & CARING's use of the work, and for any attorney's fees that AMSN incurs in the defense of such claim or lawsuit. These must be completed: I agree to have my presentation recorded                   Yes No I agree to have my presentation handout materials reproduced                  Yes No I had read the Speaker Release information and agree to the stipulations                  Yes No
Speaker Disclosure Policy & Declaration	It is the policy of the continuing education division of the ANIA & CARING to insure balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational programs.  All faculty participating in any ANIA & CARING sponsored programs, are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program.  This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic.  the intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation.  It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.  It remains up to the audience to determine whether the speaker's outside interests may reflect a possible bias in either the exposition or the conclusions presented.   With reference to products (off-label, experimental, and other,) faculty must abide by the following standards. If an unlabeled use of a commercial product or an investigational use not yet approved for any purpose is discussed during an educational activity, the speaker must disclose that the product is not labeled for the use under discussion or that the product is still under investigation. Faculty use of generic names will contribute to a balanced view of therapeutic options.  If trade names are used, those of several companies should be used rather than that of a single supporting company.
Faculty Disclosure Declaration	Name    Presentation Title                  I have no actual or potential conflict of interest in relation to this activity or presentation                   No conflict Yes conflict
Financial Interest	I have no financial interest/arrangement or affiliation with one or more organizations that could be perceived as  real or apparent conflict of interest in the context of the subject of this presentation    No financial interest I have financial interest/arrangement or affiliation with one or more organizations that could be perceived as  real or apparent conflict of interest in the context of the subject of this presentation    **Yes financial interest          **If yes, please complete the information below: Affiliation/Financial Support                                                          Name of Organization(s)                    Grant/Research Support                                                           Consultant                                                                               Speaker's Bureau                                                                    Major Stock Shareholder (not including mutual funds)                 Advisory Board                                                                        Other Financial or Material Support
Speaker Introduction Bio	Please write a 1-2 paragraph introductory biography - this will be used to introduce you as at your conference session.    Speaker Intro:
Presentation	Presentation Information  (including sending the ppt) click here

           

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Author information goes here.
Copyright © 2008 [ANIA]. All rights reserved.
Revised: 04/29/08

 All speaker information is on file and can be obtained through ANIA & CARING by submitting a written statement including your name, telephone number and reason for request.