CSCC Annual Conference Conflict of Interest Form Question Title * 1. Session Title Question Title * 2. Speaker (enter information as you would like it listed in the program materials) Name Position Organization Email Phone Question Title * 3. Audio-Visual Equipment: A laptop and projector will be provided - please specify any additional equipment you may require (e.g. flipchart) Question Title * 4. Learning Objectives: List 3 or more. The objectives should be written from the perspective of the learner, descriptive of what the learner will gain in knowledge, skills and attitudes as a result of participating in the event; and written to enable evaluation of achievement by the planners and participants.Please use verbs that denote an observable action, such as "list, explain, summarize, discuss, compare, etc." NOTE: it is not longer permitted to use words that indicate emotions or feelings such as "know, learn, appreciate, understand, recognize, etc." For a list of actionable words, please reference the "Speaker Information" page on the conference website.At the end of the session, the participants will be able to: Objective 1 Objective 2 Objective 3 Objective 4 Objective 5 Objective 6 Question Title * 5. Description: Please provide a summary of your presentation. At the end of your summary please indicate your target audience, for example, "the session will be of value to: Clinical Chemists, Trainees, and other healthcare professionals." Question Title * 6. Biography: 1-2 paragraphs; upload a document or type your bio in the next question box PDF, DOCX, DOC file types only. Choose File Choose File No file chosen Remove File Biography: 1-2 paragraphs; upload a document or type your bio in the next question box Question Title * 7. Biography: 1-2 paragraphs; type your bio here if you did not upload a file in Q6 Question Title * 8. Speaker Photo: Upload your headshot photo DOCX, DOC, JPEG, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Speaker Photo: Upload your headshot photo Question Title * 9. The Canadian Society of Clinical Chemists can make my presentation available to individuals who may be interested in accessing it by posting it online on the national association website (Members Only Section) or on the conference app (Conference Attendees Only). Yes No Question Title * 10. Speaker Signature and Date: I, the undersigned, the author of this presentation, certify that I have obtained all customary and necessary permission to use and print any copyright material that appears in my presentation. Speaker Name Date Next