Enter information about a presentation you gave as part of a larger conference, symposium or workshop. For example, let's say you presented at a conference sponsored by another ADRC. You would enter information on both the conference and your own particular presentation in the boxes below.  

If you gave more than one presentation at the same conference, please submit this form twice with the appropriate changes. The easiest way to do this is use the back key on your browser after you submit the first presentation. The information you entered should still be preserved and then you can edit it for the second submission. This also holds true for events that included more than one of our faculty members. 

Important fields are in RED. Leave blank those fields that do not apply or for which information is not available.  Contact Tom Meuser, Education Director, if you have questions.

Type of Event:  Conference Symposium Workshop Other

Title of Conference/Event:

Primary Sponsoring Organization:

Your Contact Person for the Conference:  (First Last, Affiliation)

Location of Event: (City, State and/or Country)

Regarding the individual presentation:

Last Name of Presenter: 

Date of Presentation: (e.g., 4/2/01)

Title of Presentation: 

Duration of Presentation (in hours):  (e.g., 1.25 hours)

Approximate Number in Attendance: 

Skip OPTIONAL ITEMS and go to Comments Box and SUBMIT Button

__________________________________________________________________________

OPTIONAL ITEMS

Please estimate the % of individuals present 
from the following categories:
                                                                                                 
African American       (% of total audience)

Lay / Caregiver                         (Together must add to 100%)
Physician                                  
Nurse                                        
Other Health Profession         

Did this event meet its educational and/or outreach goals? Yes Partially No

Were evaluation forms distributed?  Were Distributed Were NOT Distributed   

If Yes, what was the average overall quality rating? 

       (e.g., 4.23 on a 1-5 Scale; 5 = Excellent)

Were ADRC funds used to support this event?  No Yes TITC Yes Rural Yes Clinical Core Yes Other ADRC/HASD

_______________________________________________________________________

Comments:
You are limited to 255 characters in this box. Feel free to use abbreviations. If you have more to say, e-mail your comments with a reference to this enter to Tom Meuser, Education Director.