7305 Grand River, Suite 100 | Brighton, MI 48114-7379
Phone (810) 229-5880 | Fax: (810) 229-8947
Helpline: (800) 444-6443
E-mail: | Website:
THE VOICE OF BRAIN INJURY

CALL FOR SPEAKER APPLICATIONS

The Brain Injury Association of Michigan invites you to submit a Call for Speakers Application for one of our educational programs. Because we offer CEU’s, multiple pieces of information are required for all speakers.

Choose
Conference  / Webinars
Monthly
# of Attendees / 80 - 100
Submission
Deadline / Ongoing
Speakers Notification DateAfter

The Brain Injury Association of Michigan cannot provide for honoraria or other expenses. Thank you in advance for donating your time and talent to this worthy cause.

Single Topic Sessions may include up to 1-3 experts on a single topic. These 60 minute sessions offer the opportunity to present state-of-the- art information in the areas of treatment, life planning, rehabilitation, community integration, family support, etc. Session abstracts are based on the relevance of the subject and the content expertise of the speakers.

PRESENTATION SUBMISSION REQUIREMENTS

Move from one section to the other using the tab key. You can select the grey boxes by double clicking, and indicating “checked” in the default value.

  1. All submissions must be typed. No handwritten submissions will be accepted for consideration. Save filename as: Lastname abstract.doc
  1. To be considered this form must be complete with no missing data, including:
  1. CV/Resume attached
  2. ONA Biographical Data/ Speaker Information Form (Section D below) for each presenter
  3. Reference List/Bibliography page attached
  4. Please submit via email to

SECTION A – GENERAL PRESENTATION INFORMATION

Primary Speaker Name: ______

Last Name, First Name

Presentation Format

Webinar

___Number of Speakers (No more than 3 speakers in any one session)

Check each of the following categories:

Main AudienceTopicLevel(choose only one)

Caregivers

Administration

Case Management

Clinical Issues

Families/People with

Brain injuries

Acute Care Issues

Rehabilitation Issues

Community/Family

Support/Lifetime Issues

Children and Adolescent Issues

Research

General Brain Injury

Administrative

Basic

Intermediate

Advanced

Continue to Section B.

Primary Speaker’s Last Name _

SECTION B – PROPOSED SESSION INFORMATION

Disclaimer - As a speaker, it is essential that you understand the importance of your commitment and that you will not use this opportunity to promote or market your own facilities, program and/or services.

Please complete the Education Documentation Form on the following page.

Title of Session:

OBJECTIVES / CONTENT (Topics) / TIME FRAME / PRESENTER / TEACHING METHODS
List learner’s objectives in behavioral terms / Provide an outline of the content for each objective. It must be more than a restatement of the objective. If the content is related to Pharmacotherapeutics for APRNS, indicate that here. / State the time frame for each objective. / List the Faculty for each objective. / Describe the instructional strategies & delivery methods for each objective.
1. / A.
B.
C.
2. / A.
B.
C.
3.

References from speaker(s) to show sources of best available evidence that will be discussed (in APA format):

Primary Speaker’s Last Name _____

Presentation Summary, include a few sentences to describe the presentation, which can be used in the promotion of the webinar to help the leaner understand what will be presented (limit 80 words).

Section C – Speaker Bio

Speaker 1:

Name:

Biosketch – (Mandatory) A brief paragraph for each speaker to be used for introductions (50-100 words):

List other educational events where you have presented material:

Additional Speakers

Speaker 2:

Name:

Biosketch – (Mandatory) A brief paragraph for each speaker to be used for introductions (50-100 words):

List other educational events where you have presented material:

SECTION D –SPEAKER INFORMATION -Everyone MUST complete this section, copy & paste a blank version of Section D at the bottom of the application for additional speakers to complete if needed.

All communications will be directed to the primary speaker. The primary speaker is responsible for communicating with additional speakers.

Title of Educational Activity: Education Activity Date:

Role in Educational Activity: (Check all that apply) Nurse Planner

Content Expert

Faculty/Presenter/Author

Content Reviewer

Other – Describe:

Section 1: Demographic Data

Name with Credentials/Degrees:

If RN, Nursing Degree(s): AD Diploma BSN Masters Doctorate

Address:

Phone Number: Email Address:

Current Employer and Position/Title:

Section 3: Expertise - Presenter/Faculty/Author/Content Reviewer

Please describe expertise specific to the educational activity listed above. (If the description of expertise does not provide adequate information, we will request additional documentation.)

______

______

______

Section 4: Conflict of Interest

The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity. (See addendum for information about commercial interest.)

All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.

  • Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.
  • Evidenceofa relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
  • Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.
  • Employees of commercial interest organizations are never eligible to be on planning committees or serve as faculty for a session that pertains to their field of employment.

.

If yes, complete the table below for all actual, potential or perceived conflicts of interest**:

Check all
that apply / Category / Description
Salary
Royalty
Stock
Speakers Bureau
Consultant
Other

** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.

Section 5: Statement of Understanding

Completion of the line below serves as the electronic signature of the individual completing this Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

______

Typed or Electronic Signature: Name and Credentials (Required) Date

Section 6: *SECTION FOR OFFICE USE ONLY*Conflict Resolution (to be completed by Nurse Planner)

  1. Procedures used to resolve conflict of interest or potential bias if applicable for this activity:

(Check all that apply)

Not applicable since no conflict of interest.

Investigation indicated that there was no conflict of interest.

Removed individual with conflict of interest from participating in all parts of the educational activity.

Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the educational activity.

Not awarding contact hours for a portion or all of the educational activity.

Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation.

Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.

Other - Describe:

Nurse Planner Signature

(* If form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign the form).

Completion of the line below serves as the electronic signature of the Nurse Planner reviewing the content of this Biographical/Conflict of Interest Form

______

Typed or Electronic Signature: Name and Credentials (Required) Date

Check list:

I have completed all yellow highlighted areas/sections of this application.

I have attached all speakers CV/Resumes.

I have list above or attached a Reference List/Bibliography page for my presentation

I have completed Sections A, B C & D above;sections C & D must be completed individually for each each presenter