Outlook 2010 CE Program Proposal Submission Form

Once you have completed the entire form, click on the "Submit Form" button (at the bottom of this page). *=Required Field

First Name *

Last Name *

Email *

Credentials (PharmD, PhD, etc)

CPhA Member?
No
Yes
My Member #:

Preferred Mailing Address *

My address is: *
Home
Business

Preferred Phone Number *
My Phone is: *
Cell
Home
Business

Program Type *
Program Format: *
Standard presentation (1 speaker)
Panel presentation (2 or more speakers) If you choose this, please complete the following two boxes.
Number of panel members anticipated:


Names of panel members (if known):

(Please Explain if Program Type is Other)

Target Audience: *

Preferred Program Length: *

Program Title *

Please provide 3 – 5 learning objectives for your program: *

Please provide a brief outline/agenda of the specific points you will cover during the program: *

 

Please list all possible companies that you believe may sponsor this program (or have sponsored it in the past). Please include any companies that currently list you as participating on their Speakers Bureau:

Sponsor(s):

 

Please provide a brief program description (max: 75 words) to promote your program in the Outlook marketing materials
(should your presentation be selected): *


Please list any scheduling conflicts that you may have during the conference
(i.e. being involved in the CPhA House of Delegates, being an exhibitor, flying from the East Coast, etc.) so that if selected, your presentation can be properly placed on the overall conference schedule: *

Section 2

In addition to submitting this form, I will email a current CV and short biosketch to Shannon Presidio at spresidio@pharmacyfoundation.org. Note: A CV is required to help us ensure that our continuing pharmacy education program speakers are competent in the subject matter and qualified by experience, training and/or preparation to the tasks and methods of delivery. The biosketch will be used as your introduction, should your program be selected.
I agree *

 

Program content - To meet criteria for accreditation as established by the Accreditation Council for Pharmacy Education (ACPE) and the California State Board of Pharmacy, all continuing pharmacy education programs should provide an in-depth presentation with fair and full disclosure and equitable balance. We ask that you take the necessary steps to ensure that you will not be misinterpreted as promoting or appearing to endorse a specific commercial drug or other commercial products during your program. Product-promotion material or product-specific advertisement of any type is prohibited in or during continuing pharmacy education activities. Advertisements and promotional materials cannot be displayed or distributed in the educational space immediately before, during or after a continuing pharmacy education activity. Representatives of commercial interests are prohibited from engaging in sales or promotional activities while in the space or place of the continuing pharmacy education activity. Educational materials that are part of a continuing pharmacy education activity, such as slides, abstracts and handouts, cannot contain any advertising, trade name or a product-group message. The content or format of a continuing pharmacy education activity or its related materials must promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest. Presentations must give a balanced view of the therapeutic options. Use of generic names will contribute to this impartiality. If the continuing pharmacy education program materials or content includes trade names, where available, trade names from several companies should be used and not just trade names from a single company.
I agree to the program content guidelines *

Deadlines - If your program is selected, the following materials must be submitted by the designated due dates:

  1. Completed speaker forms (contract, W-9, A/V requests, etc.): July 31, 2009
  2. Syllabus/handout materials in electronic form: January 8, 2010
I agree to the deadlines *

 

Compensation –

In exchange for fulfilling all the requirements of the speaker contract, you will be eligible to receive

one

of the following:

Standard Presentation (only 1 speaker presenting)

  1. $400 Honorarium. Should they choose to, speakers may apply their honorarium to their conference registration fee (full or daily registration) or they may waive their honorarium and consider it a tax-deductible donation to the Pharmacy Foundation of California.
  2. One night at a host hotel at the negotiated conference rate. Room and tax only.
  3. Up to $300 in reimbursement for any reasonable travel-related expenses according to PFC’s travel reimbursement policy: Lowest generally available round trip airfare and/or mileage equivalent to current IRS allowable rate per mile, whichever is less. Other reasonable travel-related expenses will be reimbursed at actual cost and are limited to parking, car rental and fuel. Original receipts must be submitted.
  4. One full day’s allowance to cover meals and incidental expenses (shuttle, taxi, etc.) at the US GSA established per diem rate (www.gsa.gov) for the day of the presentation only.

 

Panel Presentation (2 or more speakers are presenting)

  1. $700 honorarium equally divided among all panel speakers (for example, if there are 2 speakers on the panel, each will receive $350). Should they choose to, panel members may apply their portion of the honorarium to their conference registration fee (full or daily registration) or they may waive their portion of the honorarium and consider it a tax-deductible donation to the Pharmacy Foundation of California.
  2. Each panel speaker will receive one full day’s allowance to cover meals and incidental expenses (shuttle, taxi, etc.) at the US GSA established per diem rate (www.gsa.gov) for the day of the presentation only.
I agree to the compensation guidelines *

 

Additional compensation may be available under certain circumstances and is subject to PFC approval. If you believe you may have circumstances that will require/enable additional compensation (e.g. extended travel or a pre-arranged sponsor),
please describe:

In the event that your program is not selected for the Outlook 2010 schedule, are you interested in having your program promoted to local associations and other pharmacy organizations through CPhA's CE Bank
? *
Yes
No