2023 North Central Annual Meeting Call for Programs

2023 North Central Annual Meeting Call for Programs

To Submit Your Proposal:

1. After you have completed your proposal on the Program Submission Worksheet, cut and paste the information from the worksheet into this online form. Please note: You will need to complete this online form in one sitting.

2. You will be asked to attach your Program Submission Worksheet with Primary Presenter Bio/Disclosure as well as a Co-Presenter Bio/Disclosure Form for each of your co-presenters as the last step before submitting your proposal. These documents should be attached in Word format, not PDF.

Program Title*

The title of the proposed program should reflect the content of that program. Please note: Cute titles tend to detract from the professionalism of the conference and make it harder to determine what will be presented.

Abstract*

Provide a short (75 words) descriptive abstract of your presentation. Please be concise and clear with your description. Your abstract will be inserted VERBATIM in conference materials. If your presentation will address original research, please specify. NCCHA reserves the right to edit your abstract.

Pharmacology*

Will your presentation include content related to pharmacology? Check yes or no and, if yes, please ensure that your objectives and content (below) validate the pharmacology component.

Yes

If "Other" above, please specify percentage:

Does your program address equity?*

If so, describe how it explores or addresses systemic barriers that impede marginalized populations from achieving health outcomes. These systems may include, but are not limited to social, economic, demographic, cultural, or geographic policies, processes, and practices that create barriers for specific populations.

Audience

Who is the expected learner for your program? Check all that apply, but be selective. Most programs have a primary audience (e.g. health educators, physicians, nurses). Selecting all or most disciplines when the program is for one or two specific disciplines could be misleading to the reviewers. The CE Committee uses this information to help determine CE credit for the program.

Administrator

Advanced Practice Clinican

Dietitian/Nutritionist

Health Educator/Health Promotion Specialist

Health Information Management Prof.

Mental Health Professional

Nurse

Pharmacist

Physician

Psychiatric Advanced Practice/Psychiatrist

Student

Social Worker

Other

If your expected learners includes others, please specify.

Professional Practice Gap

When there is a gap between what the professional is currently doing or accomplishing compared to what is desired/achievable on the basis of current professional knowledge, there is a professional practice gap.

The goal of a strong educational session is to change participants’ knowledge, skill, or performance in an effort to eliminate the practice gap – ultimately making a positive change in student health outcomes. With this in mind, complete the following questions so that program planners have a clear understanding of how the information presented in your session will change participants’ knowledge, skills, or performance.

Describe Practice Gap*

Briefly describe the practice gap related to your session topic.

Type of Gap*

This presentation will address a gap in:

Knowledge (participants don't know what they need to know)

Skill (participants know what they need to do but lack the tools or strategies to implement it)

Both Knowledge and Skills

Description of Current State*

(e.g., Participants do not have the information and/or skills they need to advocate for a tobacco-free campus.)

Description of Desired/Achievable State*

(e.g., Participants will have the information and/or skills needed to advocate for a tobacco-free campus.)

Learning Outcome*

Describe what the learner will be able to do as a result of participating in the educational session. (e.g., The purpose of this activity is to enable the learner to explain the steps a campus needs to take to become tobacco-free.)

Learning Objectives and Content

LEARNING OBJECTIVES: 2-3 learning objectives are recommended for a 60-90 minute session. If the presentation will address mental health issues, please ensure this is reflected in the objectives.

1. Begin each objective with one of these measurable verbs: Describe, Recite, Explain, Identify, Discuss, Review, Compare, Contrast, Define, Differentiate, List, Outline

2. Make a separate objective for each action. Each learning objective should contain only one verb and complete the phrase, “The participant should be able to…”

EXAMPLE: Define sleep deprivation and the consequences. These are two separate actions and should be split into two objectives as follows:

1. Define sleep deprivation.

2. List the consequences of sleep deprivation.

CONTENT: List specifics that will be covered under each objective. Content must be congruent with purpose and objectives and should be evidence-based or based on the best available evidence. Include details beyond a restatement of objectives. Include (1) length of time for each portion of the content and (2) the presenter (if more than one presenter) for each portion of the content. (See example below.)

EXAMPLE: Two speakers – L. Smith and J. Brown Objective: Define sleep deprivation. Content: degrees of sleep (25% / L. Smith), quantity of sleep (10% / L. Smith), quality of sleep (15% / J. Brown), circadian factors (50% / L. Smith & J. Brown) LEARNING METHOD: Include the learning method(s) for each objective. EXAMPLES of Learning Methods: Power Point presentation, Lecture, Q/A, Group Discussion, Role Play.

Learning Objective #1

Learning Objective:*

Start the objective with one of the measurable verbs listed under Learning Objectives above.

Content:*

List specifics that will be covered under this objective.

Presenter(s):*

List all presenters (first and last name) who may contribute to this objective.

Learning Method:*

What learning method will be used for this objective? (e.g., Lecture and PowerPoint, Lecture and Q&A, Group Discussion, Panel Presentation, Role Play, Small Group Activities, etc.)

Learning Objective #2

Learning Objective:*

Start the objective with one of the measurable verbs listed under Learning Objectives above.

Content:*

Presenter(s):*

Learning Method:*

Learning Objective #3 (optional)

Learning Objective:

Start the objective with one of the measurable verbs listed under Learning Objectives above.

Content:

Presenter(s):

Learning Method:

Learning Objective #4 (optional):

Learning Objective:

Start the objective with one of the measurable verbs listed under Learning Objectives above.

Content:

Presenter(s):

Learning Method:

Content can be based on:

• Information available from organizations’ website(s) (organization must use current available evidence; may be published or unpublished content; examples: Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, National Institutes of Health) • Peer-reviewed journal(s)/resource(s) • Clinical guidelines, public health practice guidelines (example: guidelines.gov) • Expert resource(s) (example: individual or educational institution’s book, article, website) • Textbooks • Best practices or new and emerging issues IF APPLICABLE: Provide specific website address, journal volume number, etc., so that the data can be easily accessed by program planners

Content for this educational activity was based on:*

(List any evidence-based references used to develop this presentation. Cite specific data, journal articles, official standards or recommendations, etc.)

Primary Presenter

Complete the following fields for the Primary Presenter.

First Name*

Last Name*

Degree(s)

(as you would list them following your name – i.e., MPH, BSN):

Job Title*

Institution/Employer*

Address 1*

Address 2

City*

State*

Zip Code*

Telephone

Email*

Primary Presenter Qualifications

Please provide complete information in this section, as presenter qualifications factor heavily in the decision-making process of the program planners and continuing education reviewers.

Academic Degree(s) and Professional Certifications

List your completed academic degree(s), institution where the degree was earned, and major or specialty area. (e.g., PhD, ABC University, clinical psychology). Also list current professional certifications (e.g., CHES, APN, LPC).

Publications

List your publications that are most relevant to the proposed topic (up to 10).

Biographical Qualification Statement*

As you prepare your bio statement, please consider the following:

• Clearly state your content expertise related to the topic of your presentation.

• Include relevant academic appointments, involvement in professional organizations, and/or awards/honors received.

• Specify the number of years you’ve been working on the program initiative, topic area, or specialty.

• Describe your involvement in implementation of research, initiative, topic area, or specialty.

• Indicate whether you have presented on this topic before.

Example: I have been working as a Psychologist in our Counseling Center for five years. My dissertation was on identity development among trans students. In my current role I primarily work with trans students, and I serve as the Co-Investigator of this study. I have presented about this research on-campus and at other national conferences.

I am qualified to give this specific presentation because:

Conflict of Interest

NCCHA is obligated to the organizations that grant us CE accreditation/approval to ensure that all educational activities are developed and presented with independence, objectivity, and scientific rigor. It is our responsibility to ensure that they are free from promotion of specific goods or services, and that they are free from actual or potential bias.

All faculty/presenters/authors/planners are required to disclose all financial relationships with any ineligible companies (defined below) that you have had over the past 24 months, regardless of the amount and regardless of whether you view the financial relationships as relevant to the education. The Program Coordinator will identify and mitigate, as appropriate, any relevant relationships and the presence or absence of relevant financial relationships for all persons in control of content will be disclosed to the participants/learners before the learner engages in the education.

Relevant relationships are defined as relationships with an ineligible company if the products or services of the ineligible company are related to the content of the educational activity.

Please note: the identification of financial relationships with ineligible companies does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity.

Ineligible Company

The ACCME defines an ineligible company as any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Nature of the Financial Relationship

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds

COI Attestation*

I have read, fully understand, and agree to adhere to the Conflict of Interest Disclosure Guidelines as outlined above.

Yes

COI Disclosure*

Required Disclosure: During the past 24 months have you had a financial, professional or personal relationship (including self-employment and sole proprietorship) with a company (as defined in the Conflict of Interest Disclosure Guidelines).

Yes

Relationship and Company

If you answered yes above, list the full company name and the specific relationship(s) below. Please also indicate whether the relationship has ended.

Content Related to Company*

If you indicated the name of company above, does the CE content over which you have control contain information about healthcare products or services of the ineligible companies you identified?

Yes (if yes, the planning committee will contact you regarding resolution of your conflict of interest)

N/A (no commercial interest identified above)

Off-Label Use of Drugs*

Will your presentation include discussion of off-label, experimental, and/or investigational use of drugs, devices, medical procedures, or interventions?

Yes

If yes, please list drugs, devices, and/or procedures to be discussed.

Electronic Signature*

By typing my name below, I am providing it to represent my electronic signature approving all the information entered in this Program Submission form. I further attest that all submitted information is accurate. I have identified all potential conflicts of interest and for those conflicts of interest that could bias my presentation, I agree to abide by the resolution of conflict as determined by NCCHA and the Program Coordinator.

Date Submitted*

Co-Presenters

If you have co-presenters, enter their information below. If you do not have co-presenters, skip to the bottom of the form. You will be asked to attach a Co-Presenter Bio/Disclosure Form for each co-presenter.

Co-Presenter #1

First Name:

Last Name:

Degree(s):

Co-Presenter #1 Job Title

Institution/Employer:

Email:

Co-Presenter #2

First Name

Last Name:

Degree(s):

Co-Presenter #2 Job Title

Institution/Employer:

Email:

Co-Presenter #3

First Name:

Last Name:

Degree(s):

Co-Presenter #3 Job Title

Institution/Employer:

Email:

Co-Presenter #4

First Name:

Last Name:

Degree(s)

Co-Presenter #4 Job Title

Institution/Employer

Additional Co-Presenters

If you have additional co-presenters, check "Yes". Please attach the Co-Presenter Bio/Disclosure Form below for all of your co-presenters.

I have more co-presenters in addition to those listed above.

Yes

File Attachments

Program Info and Presenter Bio and Disclosure Forms*

1. Program Submission Worksheet* Attach your Program Submission Worksheet that includes your Primary Presenter Bio/Disclosure in Word format (not PDF). Be sure to sign and date the worksheet before submitting it. 2. Co-Presenter Bio/Disclosure Form(s)* Attach a Co-Presenter Bio/Disclosure Form for each co-presenter. The document name should begin with the presenter’s LAST NAME. The forms must be signed and dated and submitted as Word documents.

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