2017 NECHA/NYSCHA Combined 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.

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.

Does your program contain or report original research? If yes, please specify in the abstract below.

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.

If yes, please select the estimated percentage of session content related to pharmacology.

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. NECHA/NYSCHA reserves the right to edit your abstract.

* Practice Gap: Briefly describe what the audience needs to "know" or "know how to do" that will be addressed by this session. Specify the source(s) that support the existence of this gap in knowledge and/or skills (e.g., data, standards, or other evidence-based support, personal experience)

NOTE: A professional practice gap exists 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.

Based on the description above, this presentation will address a gap in:

EXAMPLE: Smoking is allowed on campus as long as it isn't within 25 feet of any building.

EXAMPLE: The campus is or will become a tobacco-free campus.

EXAMPLE: The purpose of this activity is to enable the learner to explain the steps a campus needs to take to become tobacco-free.

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.

If your expected learners includes others, please specify.

List any evidence-based references used to develop this presentation.

Listing references is not required, but is highly recommended. Cite specific data, journal articles, official standards or recommendations, etc.

(Addressing diversity is not a prerequisite for program selection.)

Does your program address diversity? If yes, describe how it addresses diversity based on the following aspects: age; gender identity, including transgender; marital status; physical size; psychological/physical/learning disability; race/ethnicity; religious, spiritual, or cultural identify; sex; sexual orientation; socioeconomic status; military veteran status.

LEARNING OBJECTIVES: 2-3 learning objectives are recommended for a 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.

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

List specifics that will be covered under this objective.

What percentage of the total session time will this objective take?

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

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.)

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

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

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

Complete the following fields for the Primary Presenter.

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

Describe your training or experience that establishes your expertise on the proposed topic.

List your degree(s) with date and educational institution. Also list relevant certification and/or specialty areas that relate to the proposed topic (e.g., PhD in Developmental Psychology).

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

List any academic appointments.

Describe your involvement in relevant professional organizations (e.g., ACHA, NYSCHA).

List any awards/honors received.

Will the content of your materials(s)/presentation(s) in the CE activity include discussions of unapproved or investigational uses of products or devices?

Do you and/or your spouse/partner have a financial interest, arrangement, or affiliation with any organization or business entity (including self-employment and sole proprietorship) that could be perceived as a conflict of interest or a source of bias in the context of this presentation? (Relationships must be disclosed during the time when the relationship is in effect and for 12 months afterward.) Check yes or no below. If yes, also enter the name of the organization or entity next to the type of affiliation below.

Recipient of honoraria, reimbursement for expenses, or other financial assistance for this program from:

By typing my name below, I am providing it to represent my electronic signature approving all the information entered in this Call for Programs 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 the Program Coordinator.

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.

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

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.

Upload all attachments here:

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