Draft

SESSION PROPOSAL FORM

American Academy of Pediatrics

2017 National Conference & Exhibition

Chicago, IL – September 16-19

(PLEASE TYPE OR PRINT)

Sponsoring AAP Committee, Council, Section, Chapter

Proposal Author

Address

City, State, Zip

Phone

Fax
E-mail
Title (Should describe the expected content and pique interest for participation):
What is the Problem(s) that this activity addresses? (Professional Practice Gap):
Need for topic or procedure (Rationale for presentation, Update, new information, overview, application to the practice of pediatrics, correct misunderstandings):
How did you determine the problem and identify what your learners need to solve it?(Needs Assessment Data):
Learning Objectives for this session (What will participants learn or be able to accomplish as a result of attending this program?)
Teaching Method proposed to meet the objectives (Lecture, discussion, case correlation, problem solving, role play, Q & A):
Session Description (A succinct summary of the concepts and subject matter to be included in the session):
Format
(Rank as 1st & 2nd Choice ) / Audience Response Session
Interactive Group Forum
Plenary
Point-Counterpoint / Section Program for Section Members
Short Subject
Seminar

Workshop

Please see session format overview for more information on session formats.

PROPOSED FACULTY

Please list primary faculty first. (Proposal author should not be considered as faculty)

Note: NCE Planning Group Members have final decision on faculty except for Section programs.

Primary Faculty
Faculty Name (first last) / AAP member Yes No
Mailing Address
City, State, Zip
Phone: 816-326-8464
Additional Faculty(see format overview for allotted # of faculty for sessions)
Faculty Name (first last) / AAP Member Yes No
Mailing Address
City, State, Zip
Phone: / Fax: / E-Mail:
Faculty Name (first last) / AAP Member Yes No
Mailing Address
City, State, Zip
Phone: / Fax: / E-Mail:
Alternative Faculty
Faculty Name (first last) / AAP Member Yes No
Mailing Address
City, State, Zip
Phone: / Fax: / E-Mail:
Faculty Name (first last) / AAP Member Yes No
Mailing Address
City, State, Zip
Phone: / Fax: / E-Mail:
Please list anything additional about the faculty (i.e.: presentations at other conferences or AAP meetings, awards, etc):

Please check here if faculty will be speaking at a Section “H” program. Please list faculty name.

Name: ______

Please submit via ShopAAP by April 8, 2016 this is only a draft!