2018 Critical Care Transport Medicine Conference
Wyndham River Walk Hotel
San Antonio,Texas
April 9-11, 2018
All topic submissions are due no later than
*
*
August 31, 2017
Your submission will NOT be considered if the objectives and outline are
missing. Totally complete the form.
A separate set of forms must be completed for all co-presenters.
CCTMC will consider state-of-the-art, cutting-edge, advanced clinical topics.
Submit your topic electronically as a Word document to [email protected]; you will receive
confirmation that your submission has been received. Lectures should not exceed 30 minutes
including 5 minutes for QA. CCTMC offers the primary speaker a $100.00 honorarium per 30minute lecture, and complimentary registration to the conference (travel expenses are not
reimbursed). General Session lectures (as determined by the selection committee) should be 50
minutes including 5 minutes for QA, and receives a $200.00 honorarium.
Name & Degree:___________________________________________________________________
Title & Facility:____________________________________________________________________
Email:___________________________________________________________________________
Preferred Mailing Address:___________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Phone Number:__________________________Fax Number:_________________________________
Education:
Degree/Major
Institution/Location
City/State
Year
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Summarize your professional experience related to presentation/committee member: (Include previous
presentations, published articles, clinical experience related to the topic)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
List your three most notable presentations including:
1)
Title of presentation
2)
Name of conference
3)
Year
4)
Audience Size
PLEASE COMPLETE ALL OF THE FORM
Submission will not be considered without title, description, objectives and outline
Proposed Course Offering
Presentation Title:
Is this presentation
_____ Basic
_____ Intermediate
______Advanced
Presentation Description: (brief paragraph)
Category of Presentation: ____ Clinical
____ Professional Development
____ Education ____ Management ____ Research
Presentation Objectives:
1. ______________________________________________________________________
______________________________________________________________________
2. ______________________________________________________________________
______________________________________________________________________
3. ______________________________________________________________________
______________________________________________________________________
Outline of Presentation:
(an outline of the presentation must be included with this submission)
Teaching Method: (List all that apply)
____ Lecture
____ Slides/LCD
____
____
Discussion
Hands on Skills
This person’s participation is this offering includes:
Development of:
Selection of:
____ Objectives
____ Teaching Methods
____ Content
____ Handouts and Bibliography
____ Evaluation Tools
____ Other (describe)__________________________________________________
Thank you.