2018 MICNP Annual Conference:

Speaker Abstract Submission Form

The Michigan Council of Nurse Practitioners invites you to participate in the 17thannual conference

by submitting an abstract for apodium presentation.

Deadline for abstract submission is Monday, July 24, 2017

We are seeking abstracts for both one hour breakout sessions andtwo & three hour workshops.

Conference Location/Date:
MotorCity Hotel-Casino Conference Center, Detroit, Michigan
March 16-17-18, 2018

  • Two and Three hour workshops are offered on Friday, March 16
  • One hour breakouts are offered on Saturday, March 17

Submissions should be evidence-based.Please consider how the information presented can be integrated into clinical practice by the attendees.
Appropriate content:

Pharmacology:Knowledge relevant to NP practice which may include, but is not limited to: updates on new medications, prescribing within drug classifications, special population considerations in prescribing practices, or general prescribing issues such as polypharmacy or pharmacogenetics.

Areas relevant to any area of NP practice may include, but are not limited to:

  • Innovative education strategies
  • Practice improvements through use of technology
  • Diagnosis and management of acute and chronic illness, preventative care, specialty populations, and practice issues including patient centered medical home
  • Models of care such as nurse managed centers and homeless clinics, clinical innovations, and practice issues.
  • Specialties include mental health, surgical specialties, oncology, pediatrics, women's health, palliative care, neurology, geriatrics, etc.

Abstract guidelines:

Abstracts must be submitted via email using this document and returned in Word format, please do not return as a PDF document or handwritten document. Please email completed abstract by 7/24/17to the MICNP Business Office .

The form does require bio and disclosure information to be completed.If you are submitting more than one abstract, you only need to complete the bio and disclosure portion once but need to complete the ‘Learning Objective Description’ portion for each topic (page 2 of this packet). Not sure how to write your credentials? Click HERE to view the ANCC Brochure for complete details.

Timeline
June 22, 2017
Call for Abstracts Opens
July 24, 2017
Call for Abstracts Closes
Mid-August 2017
Abstract selection completed, contracts sent out / Selection Process:
The program planning committee will review submissions adhering to the guidelines and submitted prior to the deadline. A limited number of abstracts will be accepted according to limitations of conference time and space. The decisions of the program planning committee are final. We anticipate decisions to be finalized in mid-August.
Questions regarding the abstract submissions and selection process should be directed to the MICNP Business Office . We look forward to hearing from you.

2018 MICNP Annual Conference:

Speaker Abstract Submission Form

2018 MICNP Conference - LEARNING OBJECTIVE DESCRIPTION

Name & Credentials:
Presentation Title:

When completing the box below for your program objectives, the following information MUST be included:
List each individual educational objective for the program, and for each individual educational objective include the following:

  1. Learner Objectives need to be measurable - use ACTION words (discuss, list, state, identify, verbalize, etc.)
  2. Requested pharmacology minutes require pharmacology specific objectives. Identify pharmacology objectives with an (RX) in parenthesis immediately before or after the specific pharmacology objective.
  3. Content Outline - summary of major content or topic related to each objective.Pharmacology credit must be supported in this section.
  4. Identify the time frame planned for each individual objective. This should equal 60, 120 or 180 minutes based on your submission.
  5. List teaching methods for each objective, (i.e. lecture, discussion, PowerPoint, demonstration, etc.). We realize there will be Q&A during your presentation but because content of that Q&A is unknown, it cannot be applied toward CE credits so please do not list as a teaching strategy or include in your presentation time.

Select type of presentation you are submitting this abstract for:

1 hour breakout session (timeframe must equal 60 minutes, please DO NOT include Q&A)

2 or 3 hour workshop (timeframe must equal 120 or 180 minutes, please DO NOT include Q&A)

Only complete the number of objectives for your program. All 6 objectives are not required, but a minimum of 2 objectives is required.

Learning Objectives:
Identify pharmacology objectives with an (RX) in parenthesis immediately before or after the specific pharmacology objective.
At the conclusion of this activity, the participant will be prepared to: / Content (topic) Outline:
(Brief content description must be included for each objective) / Timeframe:
(in minutes for each objective) / Teaching Strategies:
(Do not include Q & A)

Pharmacology content is designed to enhance the learner’s ability to prescribe and/or monitor patients on pharmacotherapy. It includes topics such as pharmacokinetics and clinical applications of drugs. Pharmacology credit must be supported by an activity’s objectives and detailed content. Incidental mention of drugs or a pharmacological treatment does not quality for pharmacology credit.

Please provide a 3-5 sentence description of your talk for use in online conference module and/or printed materials (box will expand as you type):

Learning Objectives must:

  • Be measurable
  • Participant directed
  • Describe anticipated change in knowledge, skills, or attitude
  • And/or include action verbs

Here are some examples:

  • At the conclusion of this activity, the participant will be prepared to:
  • Describe the appropriate use of at least two antibiotics for the treatment of xxx. (RX)
  • Discuss the latest pharmacotherapuetic treatments for xxx diagnosis. (RX)
  • Classify and compare various classes of xxx drugs in the treatment of xxx. (RX)
  • Name three side effects of xxx drug. (RX)
  • Determine the difference between xxx drug and xxx drug. (RX)
  • Explain how to initiate xxx treatment option for treating xxx diagnosis. If this includes pharm, add the (RX)
  • Implement specific pharmacological treatment plans for xxx condition into practice. (RX)

2018 MICNP Annual Conference:

Speaker Abstract Submission Form

Continuing Education Faculty Biographical Sketch Form

Name (must include degree & credentials):
Mailing Address:
Contact Phone #:
Contact E-mail:
Presentation Title:

I: EMPLOYMENT INFORMATION

Present Employer:
Current Title:
Current Position Description:
(box will expand)

II: EDUCATIONAL BACKGROUND

Degree / Institution (Name, City, State) / Major Area of Study / Year Completed

III: BRIEFLY SUMMARIZE PROFESSIONAL EXPERIENCE/EXPERTISE RELATED TO TOPIC
(Please do not cut and paste your CV. The box will expand as you type)

IV: PRESENTATION EXPERIENCE

Please list your experience presenting on this subject and/or other topics. The box will expand as you type)

V: FACULTY DISCLOSURE FORM (Next Page)

All faculty MUST complete the Continuing Education FACULTY Disclosure form.

Signature: / Date:

(Electronic Signature accepted: Typed signature with date indicates electronic verification of the information provided.)

2018 MICNP Annual Conference:

Speaker Abstract Submission Form

Continuing Education Faculty Disclosure Form

Name:
Presentation Title:

SECTION I: DISCLOSURE OF FINANCIAL RELATIONSHIPS

MICNP/AANP adopts the ACCME definition of commercial interest which is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. By definition, this does not include most non-profit organizations (non-profit organizations that advocate for commercial interest are not eligible for MICNP/AANP accreditation), government organizations, or non-health care organizations. MICNP/AANP does not consider providers of clinical service directly to patients to be commercial interests. A commercial interest is not eligible for MICNP/AANP accreditation.

MICNP/AANP considers financial relationships (in the preceding 12 months) to create conflicts of interest in continuing education (CE) when individuals have both the opportunity to influence the content of a CE activity and have a financial relationship with a commercial interest. MICNP/AANP requires anyone in control of the CE content to disclose any financial relationships with commercial interest of their own and/or their spouse/partner in the preceding 12 months.

Within 12 Monthsof the date of this form, have you and/or your spouse/partner had a financial relationship or other affiliation with a commercial interest?(double click on box to check)

No (complete Section III & IV)Yes (complete Sections II, III & IV)

Signature: / Date:

(Electronic Signature accepted: Typed name with date indicates electronic verification of the information provided.)

SECTION II: NATURE OF THE FINANCIAL RELATIONSHIPS (only complete if ‘Yes’ was selected above)

Please indicate the names of the organization(s) with which you and/or your spouse/partner have a financial relationship or interest, what was received, the role, and the specific clinical areas that correspond to the relationship.Please complete all columns for each organization. If more than five relationships, please list on separate page:

Company with which Relationship Exists (indicate self or spouse/partner) / What was received?
(eg, honoraria, salary, consulting fee, stocks or stock options, royalty, travel, etc.) / For what Role?
(eg, Speakers’ Bureau, employment, consultant, advisory board, research, etc) / For what clinical area/disease state?
1. / 1. / 1.
2. / 2. / 2.
3. / 3. / 3.
4. / 4. / 4.

The following questions are for those on a Speakers’ Bureau (SB), or employed by, a commercial interest: (double click on box to check)

Are you CURRENTLY on a Speakers’ Bureau or employed by a commercial interest? Yes No

Provide the date of termination if you were previously on a Speakers’ Bureau or employed by a commercial interest in the past 12 months but have since severed the relationship:

Have you participated in company-provided speaker training related to your proposed topic? Yes No

Did you receive an honorarium or consulting fee for participating in this training? Yes No

Did the company provide you with proprietary slides/materials for your presentation? Yes No

As faculty for the CE Provider seeking accreditation with MICNP/AANP, do you intend to use slides/materials or content provided by a commercial interest for your presentation/handout? Yes No

Will your topic involve information or data obtained through training from a commercial interest? Yes No

SECTION III: DISCLOSURE OF OFF-LABEL/INVESTIGATIONAL USES OF PRODUCTS

(This section MUST be completed)

Will the content of your material(s)/presentation(s) in the CE activity include discussion of unapproved or investigational uses of products or devices? (double click on box to check) YES NO

If ‘YES’ selected above, please specify any off-label or investigational use below:

SECTION IV: COMPLIANCE WITH MICNP/AANP ACCREDIATION POLICY

(This section MUST be completed; please click on each text box and type/insert your initials for each statement below indicating you have read, understand, and are willing to comply)

I attest that the CE content for which I am responsible will be evidence-based, fair and balanced, unbiased, and free from commercial interest control.

No promotional activities may occur during CE events. This includes distribution of product brochures or product information in conjunction with the educational activity or handouts. No slides or handouts developed by a commercial interest may be used during presentations. I agree to not promote any specific proprietary or commercial business interest in my role as faculty/speaker.

I understand that an employee of a commercial interest may NOT serve as a faculty or planner of CE accredited by MICNP/AANP if the educational content that the employee controls relates to the products and/or services of the commercial interest employer. If the content DOES NOT relate to the products and/or services of the commercial interest employer, the employee may be eligible to serve as speaker or planner, but the educational content must be reviewed (should be sent with the application) before approval of CE credit will be considered.

I understand that if I serve on a Speakers’ Bureau for the same clinical area as the education activity I plan to provide, and for which accreditation is being requested, my educational activity material(s) must be submitted for a full independent review at the time of the application submission before approval for CE credit will be considered.

I understand that if I engage in a financial relationship with a commercial interest after the CE program has been granted MICNP/AANP accreditation, but before the educational activity has been implemented/delivered, I must alert MICNP and provide a new disclosure form. A second review for approval will become necessary before the activity can be delivered.

I understand that if changes are made to my educational presentation/material(s) after the CE program has been granted MICNP/AANP accreditation, but before the educational activity has been implemented/delivered, I must alert MICNP and provide information/documentation on the changes. A second review for approval will become necessary before the activity can be delivered.

If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information.

I understand that failure to disclose, false disclosure, or inability to resolve conflicts of interest will require MICNP to identify a replacement or not offer CE credit for this activity.

Signature: / Date:

(Electronic Signature accepted: Typed signature with date indicates electronic verification of the information provided.)

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