2008 Leadership Institute - Call for Presentations

October 29-31
Marriott Grand Dunes
Myrtle Beach, South Carolina

Deadline for Submission:
Monday, June 30, 2008

A seperate application form must be completed for each proposal submitted.
Title of Presentation:
Length of Presentation:
All correspondence from The Carolinas Center will be through the primary presenter. It is the responsibility of the primary presenter to communicate with other presenters.

Name of Primary Presenter:
Degrees and Credentials:
Title:
Organization:
Address:
City:
State:
Zip:
Phone:
Email:
Please state briefly your qualifications for presenting this topic.
Are there additional presenters?
Behavioral Learning Objectives: (objectives are measurable and achievable, i.e., words such as describe, explain, identify, design and apply are measurable objectives, understand is not a measurable objective)
Objective 1
Objective 2
Objective 3
Objective 4
Objective 5
Brief Abstract (no more than 50 words describing the content of the presentation):
Additional Presenter:
Title and Degrees:
Organization:
Address:
City:
State:
Zip:
Phone:
Email:
Additional Presenter:
Title and Degrees:
Organization:
Address:
City:
State:
Zip:
Phone:
Email:
Additional Presenter:
Title and Degrees:
Organization:
Address:
City:
State:
Zip:
Phone:
Email:
CNE Conflict of Interest Form
Name/Credentials
Describe your education or experience (more than your title) to support participation in this planning or presenting:
VESTED INTERESTS

I recognize that I must follow all guidelines and criteria regarding conflict of interest. Any real or perceived conflict of interest for a participant must be disclosed. For this purpose, a conflict of interest is defined as having a financial interest in a product to be discussed directly or indirectly during the educational activity; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed during the activity.
I agree to disclose to the attendees of this educational activity any limitations of data and/or any discussion of off-label, experimental, and/or investigational use of drugs or devices in my presentation or any financial interests in products or their development.

Your typed name represents your signature:
Date:
ACTIVITY DOCUMENTATION FORM
ACTIVITY TITLE:
Objectives (List objectives in operational/behavioral terms.)
Content (Topics) (List each topic area to be covered and provide a description or outline of the content to be presented.)
Time Frame (Statethe time frame for each topic area.)
Presenters (List the faculty person or presenter for each topic.)
Teaching Methods (Describe the teaching methods used for each topic.)