2021 AMDA Webinar Proposal Submission Form Question Title Submitter Contact Information: Name Company/Organization Email Address Phone Number Question Title Please enter your scheduling availability to present a webinar: January February March April May June July August September October November December Other (please specify) Question Title Please enter the month that is your first choice to schedule your webinar: Question Title Select your availability during the day to present (Select all that apply): 2:00pm Eastern 7:00pm Eastern Other (please specify) Question Title Webinar Title: Question Title Has this webinar previously been presented online or in person? Yes No If you answered "yes", when and where was it presented? Question Title Select Preferred Webinar Length:--30-Minute Webinar (A narrow topic, specific issue or innovative idea, thought leader or expert interview)--60-Minute Webinar (An in-depth discussion on a relevant topic with audience interaction, such as live or text Q&A session, panel discussion, and/or audience polls, etc.) 30-Minute Webinar 60-Minute Webinar Other (please specify) Question Title Target Audience (Select all that apply): Administrator Advanced Practitioner Attending Physician Consultant Pharmacist Fellow Nurse Practitioner IDT PACE Part-time Medical Director Physician Assistant Practice manager Researcher Question Title Practice Setting (Select all that apply): Assisted Living CCRC Community Based Practice Home Care Hospice Hospital LTC Hospital Nursing Home Sub-acute/Post-acute Next
