Provider: _______________________________ Provider #:   __________

Format: ________________________________ Date:    ______________
 (lecture, slides, discussion group, Video, CD. Cassette, Computer-Driven Instruction, etc.)

Proposed Title: _____________________________________________________

Speaker Name, Credentials, Affiliation:  List your name and credentials as they 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.
 
 
 
 
 
 
 
 
 

Instructional Level:  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: ___________________     Begin time    _____________________
Break  ______________________     Break          _____________________
Endtime: ____________________       Endtime:     _____________________
Lunch:    ____________________

CONTACT HOURS PROPOSED: _______   CONTACT HOURS:  _______ (per Committee)