ECC 2021 Speaker Submission

First Name*

Last Name*

Credentials*

Best phone number to contact you regarding your submission*

Best email to contact you regarding your submission*

I would be able to present remotely or in a virtual platform, if necessary.*

Yes

Maybe

Multiple Speakers

Multiple speakers are discouraged. If more than one speaker is necessary, please note below.

This program has multiple speakers.

Submissions

Submission of multiple sessions is highly encouraged. If you have more than three session submissions, please complete a second form.

Submission 1

Session 1: Title*

Session 1: Brief Description (to be used in program book)*

Session 1: Provide a detailed description summarizing the content for the activity, using outline or bullet points.*

Session 1: Learner Engagement Strategies*

Select or enter value

Session 1: Provide a listing of the supporting references or resources for the educational content. Evidence should be best-available, current, within past 5-7 years, especially for clinical content. For websites, provide publisher, title and date of publication as well as website address. (provide actual webpage)*

Submission 2

Session 2: Title

Session 2: Brief Description (to be used in program book)

Session 2: Provide a detailed description summarizing the content for the activity, using outline or bullet points.

Session 2: Learner Engagement Strategies

Select or enter value

Session 2: Provide a listing of the supporting references or resources for the educational content. Evidence should be best-available, current, within past 5-7 years, especially for clinical content. For websites, provide publisher, title and date of publication as well as website address. (provide actual webpage)

Session 3

Session 3: Title

Session 3: Brief Description (to be used in program book)

Session 3: Provide a detailed description summarizing the content for the activity, using outline or bullet points.

Session 3: Learner Engagement Strategies

Select or enter value

Session 3: Provide a listing of the supporting references or resources for the educational content. Evidence should be best-available, current, within past 5-7 years, especially for clinical content. For websites, provide publisher, title and date of publication as well as website address. (provide actual webpage)

Conflict of Interest Form

Please upload a completed conflict of interest form. If more than one speaker, each speaker needs to complete a conflict of interest form.

Conflict of Interest Form/Disclosure of Relevant Relationships*

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