TeamSTEPPS National Conference Call for Presenters 2013 Survey

Question Title

* 1. All correspondence regarding this proposal will be sent to Primary Presenter listed below

First Name

Last Name

Credentials

Job Title

Organization

City

State

Zip Code

Telephone

TeamSTEPPS Master Trainer? (yes/no)

Question Title

* 2. (Optional) Co-Presenter #1 Information – Please complete this page for each co-presenter.

First Name

Last Name

Credentials

Job Title

Organization

City

State

Zip Code

Telephone

TeamSTEPPS Master Trainer? (yes/no)

Question Title

* 3. (Optional) Co-Presenter #2 Information – Please complete this page for each co-presenter.

First Name

Last Name

Credentials

Job Title

Organization

City

State

Zip Code

Telephone

TeamSTEPPS Master Trainer? (yes/no)

Question Title

* 4. (Optional) Co-Presenter #3 Information – Please complete this page for each co-presenter.

First Name

Last Name

Credentials

Job Title

Organization

City

State

Zip Code

Telephone

TeamSTEPPS Master Trainer? (yes/no)

Question Title

* 5. We are interested in:

Presenting

Creating a poster for a poster session

Either

Question Title

* 6. Please state you and your co-presenters area(s) of expertise as it relates to TeamSTEPPS

Question Title

* 7. Please include a brief bio (200 words or less). Be sure to submit it in paragraph format for you and your co-presenters.

Question Title

* 8. Please indicate the key TeamSTEPPS tools your presentation highlights

Brief

Huddle

Debrief

STEP

Cross Monitoring

Feedback

Advocacy and Assertion

Two-Challenge Rule

CUS

DESC Script

Collaboration

SBAR

Call-Out

Check-Back

Handoff

N/A

Question Title

* 9. Please indicate the audience that your presentation is best suited for (ie. impatient, military, ambulatory care, home health, etc)

Question Title

* 10. Enter your Session Title (10 words or Less):

Question Title

* 11. Please provide at least 3 learning objectives

Learning Objective #1

Learning Objective #2

Learning Objective #3

Question Title

* 12. Please describe your proposed session in up to 500 words.

Question Title

* 13. Please briefly state your presentation's key take-home values.

Question Title

* 14. Please indicate the most appropriate audience experience and knowledge level for your proposed session (please consult the Education Level Criteria as listed in the Call for Presenters document)

Introductory

Intermediate

Advanced