PART I: General Information

*Proposal Submitted By:

Title:

Organization:

Contact Phone:

*Contact Email:

Proposal Submitted For:
 

Select one... General Seminar Spring Conference Annual Convention & Trade Show

PART II: Session Information

Title:

The title must clearly convey the presentation content and may be used in promotional materials, please limit to 15 words.

Description:

Please include a 200 word or less narrative as an attachment or in the space above. Be sure to include in your narrative the following information:

• How this session relates to the topics, trends, issues or challenges in long term care

• Outlines the information that will be addressed

• Identifies instructional techniques that will be used

Learning Objectives:

1.
2.
3.
Describe three learning outcomes that participants will achieve. Please limit your objectives to 15 words each. All objectives should be written as complete sentences. NOTE: If proposal is accepted for presentation, convention publications may include the learning objectives subject to editing.

Format:

Select one... Lecture Panel Case Study Workshop
Other:
Please choose the format(s) that best describe your presentation. If other, please specify. Please be as creative as possible with your instructional methods. Other than a lecture format, it is desirable to incorporate case studies, role playing, panel presentations, interactive discussions, point/counterpoint debates, interview scenarios, etc., so the audience will gain the maximum benefit from your session.

Level of Experience:

Select one... Significant (10+ Years) Moderate (5-10 Years) Limited
Please choose the level of experience that best describes the audiences best suited for your topic of presentation.

Session Length:

Please specify the range of time needed in order to provide quality education to the intended audience (be sure to label with minutes, hours, days, etc). Note: Presentations made at the Spring Conference and Annual Convention are limited to a 1 – 2 hour presentation. If selected as a speaker we may ask that you limit your session length.

NHHCA Constituency:
Please select all that apply.

Disciplines of Interest:
Please select all that apply.

PART III: Speaker Information

Presenter Information:

Speaker Name, Credentials & Title:

(exactly as you would like to be listed in event marketing materials)

Organization/Company:

(exactly as you would like to be listed in event marketing materials)

First Time NHHCA Speaker:
(or have not presented in the past 4 years)

Biographical Information:

(Provide complete accurate information, as it may be used in promotional material. Limited to 125 words, resumes and CV’s not accepted. Attach an additional sheet if necessary)

Co-Presenter Information:

Speaker Name, Credentials & Title:

(exactly as you would like to be listed in event marketing materials)

Organization/Company:

(exactly as you would like to be listed in event marketing materials)

First Time NHHCA Speaker:
(or have not presented in the past 4 years)

Biographical Information:

(Provide complete accurate information, as it may be used in promotional material. Limited to 125 words, resumes and CV’s not accepted. Attach an additional sheet if necessary)

PART IV: Compensation

PART V: References
NOTE: This section applies to all speakers that would be first time presenters or presenters who have not presented to a NHHCA audience in the past 4 years.

Provide a list of presentations made within the past year related to long term care:

Reference 1:

Name:

Title:

Work Affiliation:

Contact Number:

Email:

Reference 2:

Name:

Title:

Work Affiliation:

Contact Number:

Email:

PART VI: Disclaimer
Indicate your understanding of and willingness to comply with each statement below by checking the appropriate box. If you have any questions regarding your ability to comply, contact the NHHCA at 603-226-4900.