Outlook 2011 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 #:

[if unknown please obtain from Michelle Ornelas (916) 779-1410 x302]
Preferred Mailing Address *

My address is: *
Home
Business

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

Program Type: *
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):

Program Format *

(Please Explain if Program Type is Other)

Target Audience: *

Preferred Program Length: *

Preferred Day(s)
Thursday (2/10)
Friday (2/11)
Saturday (2/12)
Sunday (2/13)

(Based on the schedule, we may not be able to accommodate your request)
Program Title *

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

Please provide the specific points you will cover during the program in outline/agenda format. *
Describe in detail how you assessed the needs for this program. (Note: General reasons such as “Disease state prevalence” or Literature Review” are not sufficient). *
How is this program designed to meet the needs described above? *

Program Support. To keep registration fees low and make your CE program available to the greatest possible number of pharmacy professionals, it is important that we find partner organizations that can help support your program. Please provide as much detail as you can about potential supporting organizations (individual/company names, grant website addresses, phone numbers, emails, etc).
Please provide a brief program description (max: 100 words) to promote your program in the Outlook marketing materials (should you be invited). *

Please list any scheduling conflicts that you may have during the conference (e.g. CPhA House of Delegates, exhibit hall, travel from the East Coast, etc.) so that if selected, your program can be properly placed on the overall conference schedule.

 

Section 2

CV & Biosketch
I will email a current CV and short bio by June 4, 2010, to 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 bio will be used as your introduction, should you be invited to speak.

 

Development of Program Content & Non-Commercialism

Continuing education programs must be applicable to the practice of pharmacy, include active participation of the attendee, be planned independent from commercial interest and the educational content must be presented with full disclosure and equitable balance.  PFC asks that all speaker(s) comply with the following:

  • Examine all presentation content and materials carefully to ensure that the presentation will not be misinterpreted as promoting or appearing to endorse a specific commercial drug, device, product and/or service. 


  • 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, such as slides, abstracts and handouts, cannot contain any advertising, trade name or a product-group message.  This also pertains to company names, logos, etc. – please refrain from using them in slide content, in headers and/or footers and on handouts.   

  • 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 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.


  • Speaker(s) must disclose all relevant financial relationships with any commercial interest within the past 12 months.
I agree to comply with the above. *

 

Deadlines

If you are invited to speak, the following materials must be submitted by the designated due dates:

  • Completed speaker forms (contract, W-9, A/V requests, etc.): July 30, 2010

  • Syllabus/handout materials in electronic form: January 7, 2011
I agree to comply with the above. *

 

Compensation

In exchange for fulfilling all the requirements of the speaker contract, you will be eligible to receive one of the following compensation packages:   

Standard Program (only 1 speaker presenting)

  • $400 Honorarium. 

 

  • One night at a host hotel at the negotiated conference rate.  Room and tax only. 

 

  • Up to a combined total of $300 in reimbursement for any reasonable travel-related expenses according to PFC’s travel reimbursement policy, which includes:

    • Lowest generally available round trip airfare and/or mileage equivalent to current IRS allowable rate per mile

    • Other reasonable travel-related expenses limited to parking, car rental, shuttle/taxi and tolls. 

 

  • Up to two day’s allowance to cover meals and incidental expenses (i.e. tips) at the US GSA established per diem rate of $53.25/day.

 

 Panel Program (2 or more speakers are presenting)

 

  • $700 honorarium equally divided among all panel speakers (for example, if there are 2 speakers on the panel, each will receive $350). 

 

  • Each panel speaker will receive up to two day’s allowance to cover meals and incidental expenses (i.e. tips) at the US GSA established per diem rate of $53.25/day.

 
I acknowledge and accept the compensation schedules as described. *

Additional compensation may be available under certain circumstances and is subject to 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 below:

 

CPhA’s CE Bank

CPhA created an online “CE Bank” to facilitate the provision of live continuing education to pharmacy professionals throughout California.  This online database allows speakers to add programs that they are interested in delivering, while also allowing pharmacy organizations to search the database for programs that would like to host in their area.  To view CPhA’s CE Bank, go to www.cpha.com → click on “CE/Events” in the top menu bar → click on “CE Bank”.

In the event that we are unable to invite you to speak at Outlook 2011, would you be interested in having your program promoted to local associations and other pharmacy organizations through CPhA’s CE Bank?
Please choose one of the following: *
Yes, please add my program to CPhA’s CE Bank if it is not selected for Outlook 2011.
No, do not add my program to CPhA’s CE Bank if it is not selected for Outlook 2011.