Committee Form

NORTHEAST REGIONAL NURSE PRACTITIONER CONFERENCE

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* 1. Committee Member Submitting:

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* 2. New or revised:

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* 3. Slot Number:

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* 4. Date/Day/Time of Lecture:

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* 5. Speaker

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* 6. Organization and Title

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* 7. Lecture Title:

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* 8. Pharmacology credits - In 15 minute increments (Th, Fr - 0, .25, .50, .75, 1.0) (W - 0, .25, .50, .75, 1.0, 1.25, 1.50, 1.75, 2.0, 2.25, 2.50)

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* 9. Honorarium Requested: (Breakout $250; Wednesday workshop $350)

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* 10. Bullet points of what you discussed/recommend them talking about. (or objectives)

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* 11. Session Description (limit 50-60 words):

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* 12. Target Audience

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* 13. Why chosen as topic?,ie identify Learning Gap, or what new Evidence based findings/practices have changed that warrant this learning need.

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* 14. Home Address, City, State, Zip

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* 15. Contact Information
Home Phone:
Work Phone:
Cell Phone:
Email:

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* 16. Work Address, City, State, Zip

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* 17. Comments:

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