Webinar Proposal Submission Form Question Title Submitter Contact Information: Name Organization Email Address Phone Number Question Title Webinar Title: Question Title Select Preferred Webinar Length: 30-Minute Webinar (A narrow topic, specific issue or innovative idea) 60-Minute Webinar (A timely topic or emerging issue with audience interaction, such as live Q&A session, panel discussion, case study) Other (please specify) Question Title What practice-based problem (gap) will this education address?Examples: Improve care coordination; Better communication with patients and families; Want to give better feedback to students Question Title What change(s) in strategy, performance, or patient care would you like this education to help learners accomplish?Examples: Eliminate stigmatizing language from communications with patients; Improve my management skills Question Title References List relevant data sources supporting the noted issue in practice the activity is addressing. Please place each reference on a separate line.Sample Format:Author(s). Published work (Edition). (Year). Publisher location: Publisher Question Title Target Audience (Select all that apply): Administrator Advanced Practitioner Attending Physician Consultant Pharmacist Fellow Nurse Practitioner IDT Physician Assistant Practice Manager Researcher Other (please specify) Question Title Practice Setting (Select all that apply): Assisted Living CCRC Community Based Practice Home Care Hospice Hospital LTC Hospital Nursing Home PACE Sub-acute/Post-acute Other (please specify) Question Title Learning Objectives Learning objectives should describe the intended educational outcome of this activity to address a change in knowledge, competence, or performance.By the end of the session, participants will be able to: Objective 1: Objective 2: Objective 3: Objective 4: Question Title Audience Engagement Please select the audience engagement option(s) you will use during the presentation. Select all that apply. Audience Polling Brainstorming Case Study Techniques Story Telling Video/Audio Visuals Audience Chat Response Other (please specify) Question Title Please list the speakers that will participate in this activity.Format:Speaker 1 Formal Name, CredentialsEmail AddressTitle, OrganizationList the speaker’s employer(s) using company name.Speaker 2 Formal Name, CredentialsEmail AddressTitle, OrganizationList the speaker’s employer(s) using company name. Thank you for submitting a proposal. The planning committee reviews webinar proposals on an ongoing basis. Proposal submitters will receive an email notification after the review process is complete. If you have any questions, please email Linda Lang at llang@paltc.org. Submit