PRESENTER's INFORMATION

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* 1. Are you a CSPCP member? (If not, you must join prior to submitting. Membership information and eligibility are here: http://www.cspcp.ca/joinrenew/)

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* 2. First Name

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* 3. Last Name

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* 4. Email address

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* 5. Phone number

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* 6. Organization name

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* 7. Title/Position in Organization

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* 8. Palliative Care Qualifications (Certificate of Added Competence in Palliative Care, LEAP Facilitator, Academic Appointments, etc...)

CO-PRESENTER’s INFORMATION (IF APPLICABLE)

One co-presenter is allowed.  Co-presenters must be physicians.

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* 9. First name

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* 10. Last name

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* 11. Email

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* 12. Phone number

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* 13. Confirm that your co-presenter is a physician

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* 14. Is your co-presenter a palliative care physician?

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* 15. If yes… is he/she a CSPCP member? (If not, he/she must join prior to submitting.  Membership information and eligibility are here:
https://www.cspcp.ca/joinrenew/membership-categories/)

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* 16. Organization name

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* 17. Title/Position in Organization

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* 18. Palliative Care Qualifications (Certificate of Added Competence in Palliative Care, LEAP Facilitator, Academic Appointments, etc...)

CONFLICT OF INTEREST (COI)

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* 19. I understand and agree that completed and submitted COI forms are required from ALL presenters for this application to be complete. Incomplete applications will not be considered by the abstract review committee. If you have a co-presenter, it is your responsibility as the primary presenter to ensure that your co-presenter has completed his/her COI form prior to the deadline.

The COI form can be completed here: https://forms.gle/KfNgLUBN9nA3dtHZ7
If you have a co-presenter, please forward to them by copying and pasting the link.
WORKSHOP INFORMATION

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* 20. Workshop Title

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* 21. Brief description of workshop and its relevance to clinical practice in advanced level palliative medicine (250 words maximum) 
Click the right bottom corner of the box to expand each comment box.

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* 22. Learning objectives: Minimum of 3

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* 23. Identify which CANMeds roles will be addressed in your workshop (check all that apply). Definitions are provided below this question.

CANMEDS ROLES DEFINITIONS

Medical expert: knowledge, clinical and/or procedural skills
Communicator: effective doctor/patient relationships.
Collaborator: working effectively within a health care team.
Leader: collaborative leadership and management
Health Advocate: developing expertise and influence to advocate for the health and well-being of patients, communities and/or populations.
Scholar: lifelong reflective learning as well as creating, disseminating, applying and translating medical knowledge.
Professional: ethical practice, adherence to professional regulations and personal high standards of care.

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* 24. What is original about your proposed topic?

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* 25. Describe how it is evidence based.

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* 26. How will you make this workshop interactive and engage the participants? (Reminder, at least 25% of the 75-minute workshop must be interactive). We are looking for workshops that engage people to talk, think, learn, try, and interact -- as opposed to a lecture followed by Q&A.  

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* 27. Briefly describe how your workshop aligns with the 2020 conference theme "Implementing the Framework on Palliative Care in Canada”.

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* 28. Please share any experiences you have in giving presentations/workshops, particularly with a palliative care audience. Include details such as topic, audience, size, setting (e.g., conference, rounds, etc...).

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* 29. Is there anything else you would like us to know?

Thank you for submitting your proposal. It will be reviewed by the planning committee and some peer reviewers shortly after the deadline passes. 

The top 5-6 submitters, whose proposals/topics contribute to an overall well-rounded conference program, will be invited to give workshops at ALPM 2020. You will be notified of the status by early December.

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