2022 IN-VALUE-ABLE Conference Series Breakout Session Submission Form

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* 1. Your Information (person completing form):

Your Name

Your Company

Your Email

Your Office Phone

Your Cell Phone

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* 2. Speaker Information:

Speaker's Name

Speaker's Title

Speaker's Email

Speaker's Office Phone

Speaker's Cell Phone

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* 3. Co Presenter / Speaker Information (if applicable):

Speaker's Name

Speaker's Title

Speaker's Email

Speaker's Office Phone

Speaker's Cell Phone

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* 4. Please Enter Your Speaker's Bio.

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* 5. Please Enter Your Co Presenter / Speaker's Bio (if applicable)

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* 6. Alternate Speaker Information:

Alternate Speaker's Name

Alternate Speaker's Title

Alternate Speaker's Email

Alternate Speaker's Office Phone

Alternate Speaker's Cell Phone

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* 7. Please Select The Category That Best Describes Your Presentation:

Health System Transformation

Wellness, Wellbeing

Social Determinants of Health / Employment

Medical

Ancillary / Voluntary Benefits

Chronic and/or Preventable Disease Management; Musculoskeletal

Compliance

Communications & Engagement

Mental / Behavioral Health

Technology, Data Analytics, and New Digital Tools

Benefits Administration

Pharmacy

Community Integration

Other (please specify)

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* 8. Please Enter A Title For Your Presentation.

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* 9. Please Describe Your Presentation In At Least One Thoughtful Paragraph.

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* 10. Please Provide 3 Learning Objectives For Your Presentation

Learning Objective 1

Learning Objective 2

Learning Objective 3

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* 11. Please Provide The Most Recent Dates And Events Where This Material Has Been Presented (Virtual or In-Person). Preference Will Be Given To New Presentations (If new, type NEW).

Date & Venue

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* 12. Has Your Organization Presented At A Health Action Council Event Before? If Yes, Please Indicate When And Where.

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* 13. If Not Selected To Present In The IN-VALUE-ABLE Conference Series, May We Consider The Presentation For A Webinar Or Another Live Meeting?

Yes

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* 14. Any Comments Or Other Information You Would Like To Provide?

*If selected as a speaker for the 2022 IN-VALUE-ABLE Conference Series, you will need to provide a full-color headshot (300dpi), short bio, as well as a 350-word informational blog related to your presentation.

**Selected speakers are responsible for their own travel and lodging expenses.