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Professional Acknowledgment for Continuing Education
SPEAKER INFORMATION FORM Sherry Miner, ASCLS P.A.C.E.Ò Coordinator 720 W. Main St., Rochester, IL 62563-9217 PH: 217-498-0308; F: 217-498-2075; E: sherrym@ascls.org
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Name:
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Present Position:
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Business Address:
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City, State, Zip:
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Phone: Fax: Email:
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Area of expertise:
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Credentials:
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Certifications/Agency:
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Relevant Experience pertaining to the topic to be presented (papers, presentations, publications):
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Information for a Program Introduction:
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Professional Acknowledgment for Continuing EducationPROGRAM/SPEAKER INFORMATION FORM Sherry Miner, ASCLS P.A.C.E.Ò Coordinator 720 W. Main St., Rochester, IL 62563-9217 PH: 217-498-0308; F: 217-498-2075; E: sherrym@ascls.org
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Provider: ______________________________________________________ Provider #_____________
Format: _______________________________________________________ Date: _________________ (Lecture, slides, discussion group, Video, CD, Cassette, Computer-Driven Instruction, etc.)
Proposed Title: _______________________________________________________________________________ Please be brief.
Speaker Name, Credentials, and Affiliation: List your name and credentials, as they should appear in the program.
_____________________________________________________________________________________________________
List your professional affiliation, as it should appear in the program:
Description of Session: Limit to 50 words. Type or print, being as specific as possible about learning to take place.
Level of Instruction: BASIC INTERMEDIATE ADVANCED (Circle one)
BASIC: Entry level; no prior knowledge of subject necessary to attend this program;
INTERMEDIATE: Refresher course; some basic knowledge required;
ADVANCED: Highly technical; for those with at least five years of experience in a specialty area.
PROGRAM OBJECTIVES
(Please list three. May be continued with an attachment)
At the end of the session, the participant will be able to:
1. ___________________________________________________________________________
2.___________________________________________________________________________________
3.___________________________________________________________________________________
PROGRAM TIME TABLE
Begin time_________________________ End time________________________________
Break(s)______________________________ Lunch_____________________________________
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CONTACT HOURS PROPOSED: _________
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CONTACT HOURS: _________ per Committee (for Office Use Only)
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