Speaker Information Form

Question Title

* 1. Demographic Information

Name: *

Title:

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Honorarium: *

Email:

Cell Phone Number:

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* 2. Title of lecture

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* 3. Learning Objectives

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* 4. Please provide three quiz questions participants should be able to answer correctly following your presentation.

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* 5. Please provide 3 multiple choice answers for the above questions, listing the correct answer first.

1a.

1b.

1c.

2a.

2b.

2c.

3a.

3b.

3c.

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* 6. Teaching Method

Lecture

Case presentation with discussion

Workshop

Video Presentation

Live Demonstration

Supplemental Handout Material

Other (please specify)

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* 7. Please Indicate Equipment Needs

Laser Pointer

LCD Projector

Laptop

Audio for video in presentation

Other (please specify)

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* 8. We currently do not support Macs. If you have a Mac, please select one of the following options. Please note: We will not be able to directly connect your Mac to the projector the day of your presentation unless you provide the appropriate adapter.

I have a Mac, and I will bring the appropriate adapter for my Mac.

I have a Mac, and I will bring my powerpoint presentation on a flashdrive.

I do not have a Mac.

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* 9. We often record the sound and power point slides at our lectures. Do you give us permission to record your presentation?

Yes, you have my permission if you so choose

No, you do not have my permission

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* 1. Demographic Information

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* 2. Title of lecture

Question Title

* 3. Learning Objectives

Question Title

* 4. Please provide three quiz questions participants should be able to answer correctly following your presentation.

Question Title

* 5. Please provide 3 multiple choice answers for the above questions, listing the correct answer first.

Question Title

* 6. Teaching Method

Question Title

* 7. Please Indicate Equipment Needs

Question Title

* 8. We currently do not support Macs. If you have a Mac, please select one of the following options. Please note: We will not be able to directly connect your Mac to the projector the day of your presentation unless you provide the appropriate adapter.

Question Title

* 9. We often record the sound and power point slides at our lectures. Do you give us permission to record your presentation?

Question Title

* 10. Please list any article citations you would recommend as resources for our staff to learn more on your topic.