2012 AiA- CLOSED: Late Proposal Submission Form

This form has now closed. Please use the Late-Breaking workshop form at https://www.surveymonkey.com/s/LF6HFPX or the late-breaking posters/peer group form at https://www.surveymonkey.com/s/HQDQ5QV to submit your proposal.

Questions related to the proposal submission process or the conference? Please email facultyinfo@asaging.org. Thank you for your valuable submission to ASA 2012 Aging in America.

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* 1. You must designate an authoring Author-Presenter -- the person submitting this proposal. You will be able to add up to five (5) additional Co-Presenters in questions 9-13 below. As the Author-Presenter, you will be automatically added as a presenter.

If you are not the authoring Presenter or a designated representative, please contact this person since s/he needs to complete this proposal.

Salutation (Mr/Mrs/Ms/Dr):

First Name:

Last Name:

Degrees (e.g., MSW, PhD):

Company:

Title:

Phone:

Email #1:

Email #1 (repeat):

Email #2 (alternate):

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* 2. As primary presenter, I will personally complete (or review and approve) my proposal(s) and coordinate the session’s co-presenters. (Exception: If you are proposing a poster with no co-presenters, mark “yes”.)

Note number of presenters required for session formats (for ASA workshops only):

• 90-minute session: 3 to 6 presenters
• 60-minute session: 2 to 6 presenters
• Poster Session: 1 to 6 presenters

Yes

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* 3. Fees: If invited to present, I agree to pay my discounted faculty registration shown below and register upon notification by the deadline of December 15, 2011 to be confirmed as a faculty member.

2012 Aging in America Faculty Registration Rates
Full conference registration only (no single day fees)

Faculty ASA Member $415
Faculty Senior ASA Member (retired only) $310
Faculty Student ASA Member (full-time) $210
Faculty NCOA Member $525
Faculty Non-member $620
Faculty Senior Non-member (retired only) $465
Faculty Student Non-member (full-time) $365

Yes

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* 4. Co-Presenter communications: My co-presenter(s) have agreed to register immediately after notification and pay the discounted faculty registration rates if invited to present at the conference.
(Mark "yes" if you are proposing a poster session.)

Please note that Volunteer rates are not available to faculty members since presenter rates cover audiovisual and other presentation-related expenses. Presenters must register at the faculty rate with no exceptions. Contact facultyinfo@asaging.org with any questions about this policy.

Yes

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* 5. If presenting a workshop, I agree to register two (2) presenters at minimum to confirm a 60-minute session or three (3) for a 90-minute session. If presenting a poster session, I agree to register one (1) presenter at minimum to confirm the session. (All presenters must register by 12/15/11.) If no, please contact facultyinfo@asaging.org.

Yes

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* 6. Multiculturalism and Aging

Does your proposal(s) address the needs and interests of a diverse aging population as described in the diversity statement below? (Explain how in your session description and objectives.)

Diversity Statement: ASA is committed to advancing a world-class standard of professionalism in aging, with the inclusion of diversity and cultural competence as a core component. By participating as part of our conference programming, all faculty members are expected to include diversity-related content within their presentations to the extent possible. Examples might include describing differences in service use, needs or preferences among diverse population; known or potential access barriers for diverse populations; culturally appropriate outreach and education strategies; opportunities for improving access among diverse population; describing research findings based on samples drawn from diverse populations and backgrounds, etc. Conference staff assistance will gladly be provided to any presenters who need assistance with incorporating diversity content into their presentations. Please contact facultyinfo@asaging.org if you have such a need.

Yes

If NO, please explain:

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* 7. My proposal(s) primarily promotes a product or service. (Although you can share your credentials and website during the session, workshops and posters must be mainly educational in nature; generally, the exhibit hall is the appropriate venue for direct promotion of products and services. No sales of products or services are allowed under any circumstances in workshops or poster sessions.)

If your answer is “yes,” please contact Linda Jones at 415-974-9638 (ljones@asaging.org) to discuss hosting an exhibit. For general questions about this policy, please contact facultyinfo@asaging.org.

No (my session is primarily educational in nature)

Yes (my session is primarily promotional)

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* 8. Proposed Title of your session (titles, descriptions, and objectives may be edited for clarity and marketability)

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* 9. Use the following five questions to enter information on your co-presenter(s)

Co-Presenter (1) Contact Information:

First Name:

Last Name:

Degree/Credential:

Company:

Title:

Phone:

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* 10. Co-Presenter (2) Contact Information:

First Name:

Last Name:

Degree/Credential:

Company:

Title:

Phone:

Email:

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* 11. Co-Presenter (3) Contact Information:

First Name:

Last Name:

Degree/Credential:

Company:

Title:

Phone:

Email:

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* 12. Co-Presenter (4) Contact Information:

First Name:

Last Name:

Degree/Credential:

Company:

Title:

Phone:

Email:

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* 13. Co-Presenter (5) Contact Information:

First Name:

Last Name:

Degree/Credential:

Company:

Title:

Phone:

Email:

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* 14. Financial Disclosure

Conflict of interest disclosure: All presenters, speakers, and content experts must disclose to the audience, prior to the activity, whether or not there are:

1) any vested or financial interest(s) or relationship(s) with the manufacturer(s) of commercial product(s) or provider(s) of commercial services or commercial supporters

2) any uses of unlabeled products or products under investigational use. Disclosure does not prohibit the provision of courses or the awarding of CE credit; merely, there must be proper planning, proper disclosure, and the proper documentation kept on file. Disclosures should cover relationships in place currently or up to 12 months preceding the activity.

Please mark any real or perceived conflicts of interest that exist "Yes"; otherwise, choose "No"

	Yes	No
Educational or Research Grant	Educational or Research Grant Yes	Educational or Research Grant No
Consultant or Speaker	Consultant or Speaker Yes	Consultant or Speaker No
Shareholder	Shareholder Yes	Shareholder No
Other (e.g., working with products that are unlicensed or under investigation).	Other (e.g., working with products that are unlicensed or under investigation). Yes	Other (e.g., working with products that are unlicensed or under investigation). No

If yes, describe the organization, nature of interest, relationship, or commercial support.

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* 15. Your Professional Information

Membership Status of Primary Presenter: Membership in ASA is not required to submit a presentation. However, other considerations being equal, preference will be given to applications from members.

Learn more about joining ASA at www.asaging.org or email membership@asaging.org.

Check as many as apply:

American Society on Aging

ASA Constituent Group program planner/presenter

New Ventures in Leadership (NVL) partner

Student (Undergraduate or Graduate, full-time, in accredited four year institution)

Other/not applicable:

Other (please specify)

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* 16. Highest Degree Completed. Please indicate the Major, Institution, and Year Completed:

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* 17. Additional Degree Completed. Please indicate the Major, Institution, and Year Completed:

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* 18. Certifications/Licenses: Please list for session review and accreditation purposes:

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* 19. Related Professional Experience.

Established Professional – 10 or more years

Professional – 5 to 9 years

Emerging Professional – less than 5 years – or Student

Other

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* 20. Please provide a well-defined two to three sentence description. Well-written, clear and compelling session summaries carry the greatest weight in session selection. Make sure to spell check!
(500 character limit)

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* 21. Learning Objectives

Please list two to three learning objectives. What new knowledge will attendees gain or skills will they master as a result of your session? (1000 character limit)

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* 22. Outcomes/Conclusions:

If this was a project, how was it successful or unsuccessful? Why? Is your project, researach or practice replicable in other settings? (1000 character limit)

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* 23. Categorization of Session

Please select ONE bullet-pointed topic that best describes your presentation. The categories are also shown below so if you are in doubt about the topic area, please choose the numbered category (such as “1. Business and Aging”) and ASA will decide.

(Note: Although your topic choice may be revised by program staff, attendees will also be able to "search the sessions" by key words and speaker name to find your event.)

1. Business and Aging [Please choose a bullet-pointed topic underneath this category]

o Age Discrimination and Other Legal Issues

o Boomer Lifestyles and Consumers

o Business Development

o Finances in Later Life

o Marketing and Communications

o Older Adults as Consumers

o Products and Services

o Retirement Planning and Transitions

o Technology as a Business Tool

o Workforce Issues

2. Caregiving [Please choose a bullet-pointed topic underneath this category]

o Care Transitions

o Chronic Care

o End-of-Life Issues and Palliative Care

o Home-based Services and Products

o Intergenerational Families

o Long Term Care

3. Community-based Programs and Lifelong Learning [Please choose a bullet-pointed topic underneath this category]

o Adult Day Services

o Arts, Creativity, and Humanities

o Civic Engagement

o Crime Prevention

o Elder Abuse

o Emergency Preparedness

o Home and Community-based Programs

o Hospital-based Programs

o Lifelong Learning

o Recreation & Leisure

o Senior Centers

o Service Delivery

o Staff Education & Training

4. Housing, Accessibility, and Technology [Please choose a bullet-pointed topic underneath this category]

o Aging in Place

o Assisted Living

o Disabilities/Accessibility

o Functional Ability & Rehabilitation Housing

o Livable Communities

o Shared Residential Settings

o Technology: Environment and Health

o Transportation

5. LGBT Aging [Please choose a bullet-pointed topic underneath this category]

o Health Disparities

o LGBT Aging Topics

o Services and Programs

o Socio-Economic Disparities

6. Mental Health and Aging [Please choose a bullet-pointed topic underneath this category]

o Behavioral Health

o Brain Health/Cognitive Health

o Mental Health

o Substance Abuse/Use

7. Multicultural Aging [Please choose a bullet-pointed topic underneath this category]

o Cultural Competency

o Global Aging

o Health Disparities

o Immigration

o Multicultural Aging Topics

o Socio-Economic Disparities

8. Physical Health and Aging [Please choose a bullet-pointed topic underneath this category]

o Alzheimer’s Disease and Related Dementias

o Chronic Disease Management

o Clinical Issues

o Health Promotion and Wellness

o Medicines & Medication Management

o Nutrition and Supplements

o Physical Health

o Sexuality and Sexual Health

9. Policy and Advocacy [Please choose a bullet-pointed topic underneath this category]

o Advocacy Initiatives

o Elder Rights

o Healthcare Reform

o Livable Communities/Environments

o Medicare

o Older Americans Act

o Politics of Aging

o Social Security

10. Religion and Spirituality [Please choose a bullet-pointed topic underneath this category]

o Ethical Topics

o Grief and Loss

o Religion and Spirituality

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* 24. First Choice of session types (note: if only proposing one session type, choose the same answer for this question and the next).

90-minute session: 3 to 6 presenters

60-minute session: 2 to 6 presenters

Poster Session: 1 to 6 presenters

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* 25. Second Choice of session types

90-minute session: 3 to 6 presenters

60-minute session: 2 to 6 presenters

Poster Session: 1 to 6 presenters

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* 26. Target Audience

Established Professional – 10 or more years

Professional – 5 to 9 years

Emerging Professional – less than 5 years – or Student

All

Other (please specify)

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* 27. Presentation Methods - check all that apply

Poster session (one hour informal discussion, Q&A)

PowerPoint Lecture

Panel Discussion

Group Discussion

Demonstration

Video Segment (additional AV charges may apply)

Small Group or Interactive Exercise

Case Studies

Other (please specify)

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* 8. Proposed Title of your session (titles, descriptions, and objectives may be edited for clarity and marketability)

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* 9. Use the following five questions to enter information on your co-presenter(s)Co-Presenter (1) Contact Information:

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* 10. Co-Presenter (2) Contact Information:

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* 11. Co-Presenter (3) Contact Information:

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* 12. Co-Presenter (4) Contact Information:

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* 13. Co-Presenter (5) Contact Information:

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* 16. Highest Degree Completed. Please indicate the Major, Institution, and Year Completed:

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* 17. Additional Degree Completed. Please indicate the Major, Institution, and Year Completed:

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* 18. Certifications/Licenses: Please list for session review and accreditation purposes:

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* 19. Related Professional Experience.

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* 20. Please provide a well-defined two to three sentence description. Well-written, clear and compelling session summaries carry the greatest weight in session selection. Make sure to spell check! (500 character limit)

Question Title

* 21. Learning Objectives Please list two to three learning objectives. What new knowledge will attendees gain or skills will they master as a result of your session? (1000 character limit)

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* 22. Outcomes/Conclusions:If this was a project, how was it successful or unsuccessful? Why? Is your project, researach or practice replicable in other settings? (1000 character limit)

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* 24. First Choice of session types (note: if only proposing one session type, choose the same answer for this question and the next).

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* 25. Second Choice of session types

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* 26. Target Audience

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* 27. Presentation Methods - check all that apply

* 9. Use the following five questions to enter information on your co-presenter(s)

Co-Presenter (1) Contact Information:

* 20. Please provide a well-defined two to three sentence description. Well-written, clear and compelling session summaries carry the greatest weight in session selection. Make sure to spell check!
(500 character limit)

* 21. Learning Objectives

Please list two to three learning objectives. What new knowledge will attendees gain or skills will they master as a result of your session? (1000 character limit)

* 22. Outcomes/Conclusions:

If this was a project, how was it successful or unsuccessful? Why? Is your project, researach or practice replicable in other settings? (1000 character limit)