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* 1. Requestor Name:

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* 2. Requestor title/affiliation:

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* 3. Other speakers and affiliations:

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* 4. Is one or more of the presenters an AAOMPT member:

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* 5. Is one or more of the presenters an AAOMPT Fellow:

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* 6. Conference Title:

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* 7. Conference Date:

Date

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* 8. Conference Audience:

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* 9. The format of the conference:

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* 10. Link to call for session proposals:
*If no link is available, please provide the following information: length of session, due date for session proposals, max references, and any other information that outlines the guidelines for presentation.

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* 11. Details on current status of submission: (Please provide details on where you currently stand in the submission process (e.g., concept, abstract has been developed and not submitted, submission has been accepted, presentation has been started but not completed, etc.)

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* 12. Details on proposed session: (Please provide details on the current status of the concept/topic. Please include any references that will guide/contribute to the development/content.)

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* 13. Mentorship Preferences:

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* 14. Please rate your confidence in presenting this material without the assistance of the education committee:

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* 15. Please rate how much assistance you feel you need from the education committee to successfully develop and present this material:

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* 16. Which of the following components do you feel you need assistance with from the education committee? (select all that apply)

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* 17. Do you have any conflicts of interest to disclose

*Conflicts of interest may include affiliations with or involvement in any organization or entity with any financial interest (such as honoraria, educational grants, participation in speakers’ bureaus, membership, employment, consultancies, stock ownership, or other equity interest, and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this presentation.

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* 18. If yes to above, please describe below:

*Please note: Current assistance is available to AAOMPT members and/or AAOMPT fellows in good standing who are not established presenters, is not eligible for AAOMPT and CSM conferences, and does not guarantee acceptance of the session proposal. It is the right of the education committee to decline assistance if they feel they cannot provide appropriate guidance on the topic, if the conference/audience is not deemed appropriate, if a conflict of interest is present, if there is an ethical concern related to the presentation/topic, or if the timeframe for assistance is insufficient.

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