2018 Critical Care Transport Medicine Conference

Wyndham River Walk Hotel

San Antonio,Texas

April 9-11, 2018

All topic submissions are due no later than August 31, 2017

* Your submission will NOT be considered if the objectives and outline are missing. Totally complete the form.

* A separate set of forms must be completed for all co-presenters.

CCTMC will consider state-of-the-art, cutting-edge, advanced clinical topics.

Submit your topic electronically as a Word document to ; you will receive confirmation that your submission has been received. Lectures should not exceed 30 minutes including 5 minutes for QA. CCTMC offers the primary speaker a $100.00 honorarium per 30-minute lecture, and complimentary registration to the conference (travel expenses are not reimbursed). General Session lectures (as determined by the selection committee) should be 50 minutes including 5 minutes for QA, and receives a $200.00 honorarium.

Name & Degree:______

Title & Facility:______

Email:______

Preferred Mailing Address:______

______

______

Phone Number:______Fax Number:______

Education:

Degree/Major Institution/Location City/State Year

______

Summarize your professional experience related to presentation/committee member: (Include previous presentations, published articles, clinical experience related to the topic)

______

List your three most notable presentations including:

1)  Title of presentation

2)  Name of conference

3)  Year

4)  Audience Size

PLEASE COMPLETE ALL OF THE FORM

Submission will not be considered without title, description, objectives and outline

Proposed Course Offering

Presentation Title:

Is this presentation _____ Basic _____ Intermediate ______Advanced

Presentation Description: (brief paragraph)

Category of Presentation: ____ Clinical ____ Education ____ Management ____ Research

____ Professional Development

Presentation Objectives:

1.  ______

______

2.  ______

______

3.  ______

______

Outline of Presentation:

(an outline of the presentation must be included with this submission)

Teaching Method: (List all that apply)

____ Lecture ____ Discussion

____ Slides/LCD ____ Hands on Skills

This person’s participation is this offering includes:

Development of: Selection of:

____ Objectives ____ Teaching Methods

____ Content ____ Handouts and Bibliography

____ Evaluation Tools

____ Other (describe)______

Thank you.