2016 Northwest Patient Safety Conference: Call for Speakers and Posters

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The application deadline is January 25th, 2016

Session Description

This year's conference theme is Patients and Families as Partners in Safe Care. Please include in the description of your proposal how you will address this theme.

Are you submitting this form for a presentation or a poster? *

Presentation
Poster

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If your proposal for a presentation is NOT selected, do you want it to be considered for a poster? *

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Presentation Format *

*Please see our "Call for Speakers" at for more detailed descriptions of session formats. Please check the box of your preferred presentation method.

Workshop
60 minute session
High-intensity talk
Poster

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Title of presentation or poster *

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Session Description *

Please limit to 350 words

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Relation to Conference theme *

Please explain how your topic specifically relates to the Conference theme: Patients and Families as Partners in Safe Care

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Please Identify 2-3 learning objectives for this presentation or poster *

Must be fewer than 350 characters.

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Audience

This session is best suited for someone who is a(n): *

Please check all that apply

Beginner in patient safety topics
Intermediate in patient safety topics and terminology
Advanced or expert in patient safety or this particular presentation topic
All experience levels

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Presenter Information

If your presentation requires more than one speaker, please identify a lead speaker. You will be asked to explain the need for additional speakers in a later question.

Lead Presenter *

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Leader Presenter Job Title *

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Lead Presenter Email *

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Lead Presenter Organization Name *

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Lead Presenter Phone Number *

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Lead Presenter Bio *

Please summarize your bio as it is relevant to this presentation topic. (please limit to 175 words)

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Experience or expertise on the presentation topic *

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Do you have any relevant relationships or commercial interests to disclose? *

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Reference Name *

Please provide one reference who can validate your expertise or presentation effectiveness

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Reference Email *

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Reference Phone *

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Co-Presenter Name

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Co-Presenter Job Title

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Co-Presenter Email

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Co-Presenter Organization Name

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Co-Presenter Bio

Please summarize your bio as it is relevant to this presentation topic. (Please limit to 175 words)

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Co-Presenter experience or expertise on the presentation topic

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Do you have any relevant relationships or commerical interests to disclose?

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Reference Name

Please provide one reference who can validate your expertise or presentation effectiveness

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Reference Email

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Reference Phone

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Co-Presenter Name

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Co-Presenter Job Title

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Co-Presenter Email

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Co-Presenter organization name

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Co-Presenter Bio

Please summarize your bio as it is relevant to this presentation topic. (Please limit to 175 words)

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Co-Presenter experience or expertise on the presentation topic

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Co-Presenter Name

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Co-Presenter job title

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Co-Presenter Email

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Co-Presenter organization name

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Co-Presenter Bio

(Please limit to 175 words)

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Co-Presenter experience or expertise on the presentation topic

This is a required question

Co-Presenter Name

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Co-Presenter Job title

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Co-Presenter Email

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Co-Presenter organization name

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Co-Presenter Bio

(Please limit to 175 words)

This is a required question

Co-Presenter experience or expertise on the presentation topic

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Please explain the need for more than one speaker in this session

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Speaker Support Request

Limited funds may be available for travel and for lodging stipends upon request. Please describe your anticipated needs.

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