Speaker Information Form Question Title * 1. Demographic Information Name: * Title: Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Honorarium: * Email: Cell Phone Number: Question Title * 2. Title of lecture Question Title * 3. Learning Objectives 1 2 3 Question Title * 4. Please provide three quiz questions participants should be able to answer correctly following your presentation. 1 2 3 Question Title * 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. Question Title * 6. Teaching Method Lecture Case presentation with discussion Workshop Video Presentation Live Demonstration Supplemental Handout Material Other (please specify) Question Title * 7. Please Indicate Equipment Needs Laser Pointer LCD Projector Laptop Audio for video in presentation Other (please specify) 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. 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. Question Title * 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 Question Title * 10. Please list any article citations you would recommend as resources for our staff to learn more on your topic. Submit