NAMI Illinois 2010 Annual Conference

Transcription

1 NAMI Illinois 2010 Annual Conference OCTOBER 15-17, 2010 EMBASSY SUITES PEORIA, ILLINOIS WORKSHOP PRESENTATION PROPOSAL FORM NAMI Illinois encourages submission of proposals for workshops for its 2010 Annual Conference scheduled for October 15-17, 2010 at the Embassy Suites in Peoria, Illinois. Our theme this year will be Learning Together Changing Minds. Workshop presentation proposals are sought on the many issues of importance to consumers, family members, mental health professionals, and advocates, including services, research, forensic issues, housing, employment, outreach to diverse populations, consumer-run programs, fundraising, and others, especially those that focus on our theme. Competition for a limited number of presentations is keen. The information we receive on this form is the ONLY information we will receive about your proposal. Please be clear and concise and do your best to ensure that members of the Conference Committee will understand why this presentation is important, what information you intend to convey, and what you hope to accomplish. All proposals will be reviewed by members of the committee. Before submitting your proposal, please review the information below carefully: All workshop presenters are responsible for their own hotel and travel arrangements and expenses. All presenters must register for the convention if they wish to attend sessions and receive meals. Workshop presenters will receive a discounted registration fee. Workshops are 90 minutes in length. This form must be COMPLETE! Incomplete forms will not be reviewed. Please submit a complete form only once. A single page of additional information that may be helpful in the review process may be attached to your proposal. Please feel free to attach additional information such as brochures, booklets, etc. You are strongly encouraged to prepare handouts for your workshop. Our attendees love to receive handouts of your presentations. We would love your permission to place your conference presentation PowerPoint on our website after the conference is concluded. Please mark if that will be available.

2 PROPOSALS MUST BE RECEIVED BY NAMI ILLINOIS BY March 31, 2010 YOU WILL RECEIVE A DECISION ON YOUR PROPOSAL BY April 15, 2010 PLEASE TYPE OR PRINT CLEARLY PLEASE FILL OUT COMPLETELY! I WOULD LIKE THIS PROPOSAL CONSIDERED FOR A WORKSHOP. WORKSHOP TITLE: PRESENTATION TIME IS LIMITED TO 90 MINUTES FOR BREAKOUT SESSIONS THE INTENDED AUDIENCE FOR THIS PRESENTATION IS PRIMARILY: CONSUMERS FAMILY MEMBERS TREATMENT PROFESSIONALS OTHERS PLEASE SPECIFY WHY SHOULD THIS PRESENTATION BE MADE AT THE NAMI ILLINOIS CONFERENCE? WHAT IS THE PRIMARY MESSAGE YOU WANT TO CONVEY? PLEASE LIST THREE LEARNING OBJECTIVES FOR THIS PRESENTATION: IN THE LAST TWO YEARS, THIS PRESENTATION HAS BEEN MADE TO HOW MANY: LOCAL NAMI AFFILIATES NAMI STATE ORGANIZATIONS CONSUMER GROUPS PROFESSIONAL GROUPS IF THIS PRESENTATION HAS BEEN MADE BEFORE AT A NAMI NATIONAL CONVENTION, PLEASE LIST THE YEAR(S):

3 PLEASE PROVIDE A DESCRIPTION OF YOUR PRESENTATION. DESCRIPTIONS SHOULD BE NO MORE THAN 50 WORDS. IF YOUR PROPOSAL IS ACCEPTED FOR A WORKSHOP PRESENTATION, THIS DESCRIPTION WILL BE PRINTED IN THE CONVENTION PROGRAM. PLEASE BE CLEAR AND CONCISE, AND TYPE OR PRINT CLEARLY. IF SELECTED TO PRESENT, AN OUTLINE OR YOUR POWERPOINT WILL BE NEEDED ONE MONTH PRIOR TO THE CONFERENCE IN ORDER THAT WE MAY RECEIVE NURSING CREDENTIALING. PLEASE PROVIDE COMPLETE INFORMATION FOR EACH SPEAKER IN YOUR PRESENTATION. A BRIEF BIOGRAPHICAL SKETCH (IF SELECTED THIS WILL BE USED IN THE PROGRAM BOOK- APPROX. 50 WORDS) MUST BE ATTACHED FOR EACH SPEAKER AS WELL AS ILLINOIS NURSES ASSOCIATION BIOGRAPHICAL DATA FORM AND CONFLICT OF INTEREST FORM. COMPLETE CONTACT INFORMATION MUST BE PROVIDED FOR EACH SPEAKER LISTED. MODERATOR: SPEAKER #1 NAME: NAME: PROFESSIONAL TITLE: PROFESSIONAL TITLE: AFFILIATION: AFFILIATION: STREET/PO BOX: STREET/PO BOX: CITY, STATE, ZIP: CITY, STATE, ZIP: DAYTIME PHONE: DAYTIME PHONE: SPEAKER #2: SPEAKER #3 NAME: NAME: PROFESSIONAL TITLE: PROFESSIONAL TITLE: AFFILIATION: AFFILIATION: STREET/PO BOX: STREET/PO BOX: CITY, STATE, ZIP: CITY, STATE, ZIP: DAYTIME PHONE: DAYTIME PHONE:

4 SPEAKER #4: NAME: PROFESSIONAL TITLE: AFFILIATION: STREET/PO BOX: CITY, STATE, ZIP: DAYTIME PHONE: THIS SECTION MUST BE COMPLETED As the submitter of this proposal, I understand that I will be the primary contact for NAMI Illinois. It is my responsibility to relay all information received from NAMI Illinois to all participants in this presentation in a timely manner. I have read, understand, and agree to abide by these guidelines. NAME: TITLE: AFFILIATION: MAIL THIS FORM TO: NAMI ILLINOIS 218 WEST LAWRENCE SPRINGFIELD, ILLINOIS STREET/PO BOX: CITY, STATE, ZIP: DAYTIME PHONE: FORMS MUST BE RECEIVED BY MARCH 31, SIGNATURE: IMPORTANT NOTE: THE WORKSHOP SUBMITTER S NAME WILL NOT APPEAR IN THE CONVENTION PROGRAM AS A PRESENTER UNLESS LISTED AS A SPEAKER OR MODERATOR. EQUIPMENT NEEDS: PLEASE LIST ALL EQUIPMENT YOU WILL NEED FOR YOUR WORKSHOP.

5 ILLINOIS NURSES ASSOCIATION BIOGRAPHICAL DATA FORM INSTRUCTIONS: Please complete the entire form and make as many copies of it as necessary. Do not attach additional material such as CURRICULUM VITAE. Role: Please check the applicable role below. Note: An individual may fill both roles. Planner: Individual who is involved in the planning of the entire activity and identified as such in the application. Presenter/Content Specialist: Individual who is presenting or developing the content/topic areas. Check below all of your degrees in nursing and other disciplines. Nursing degrees/diplomas: Diploma Associate Baccalaureate Masters Doctorate Degrees in areas other than nursing: Associate Baccalaureate Masters Doctorate Name and Credentials: Preferred address (include city, state and zip code): Preferred phone: address: Present position (title) and name of employer: Presenters/Content Specialists: Describe your expertise in relation to the topic(s) being presented. Note: A planner is not required to complete this section unless he/she is also a presenter/content specialist. Planners: Describe your professional experience related to your role in planning this activity. Note: A presenter/content specialist is not required to complete this section unless he/she is also a planner. INA Biographical Data Form 11/06; Modified 7/08

6 PLANNER AND PRESENTER/CONTENT SPECIALST CONFLICT OF INTEREST/COMMERCIAL SUPPORT STATEMENT Purpose: In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners, faculty and authors must make full disclosure indicating whether the planner, faculty or author and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners and presenters/content specialists participating in CNE activities must disclose to the audience information listed below. Name: Title of Activity: Please indicate your role in this activity: Presenter/ Content Specialist (Check all that apply) Planning Committee Member Commercial Interest: INA/ANCC defines an entity that has a commercial interest as any proprietary entity producing health care goods or services, with the exception of non-profit or government organizations. Financial Relationships: INA/ANCC defines financial relationships as those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include contracted research where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. Relevant Financial Relationships: INA/ANCC defines a conflict of interest as when an individual has an opportunity to affect CNE content with products or services from a commercial interest with which he/she has a financial relationship. Off-label: Using products for a purpose other than that for which it was approved by the Food and Drug Administration (FDA) Spouse/ Type of Financial Relationship Name of Company(ies) Self Partner Speaker s Bureau Grant/Research Support (Principal investigator or working directly for company/company s agent) Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds) Honoraria Salary Other (Describe): A. Is there a potential conflict of interest? (check one) No Yes (Provide the information below) B. If YES to item A above, please check below how the conflict of interest will be resolved? (check one) Have discussed this conflict with individual who is now Presenter has signed a statement that says s/he will aware and agrees to our policy present information fairly and without bias. Nurse Planner or designee will monitor session to Other: Describe: ensure conflict does not arise. C. Presenters only: Discussion of off label uses: No Yes If yes, you must disclose this information during your presentation. How will you do this? (check one) Verbal statement during the presentation Information provided on handouts Information provided in audiovisuals (slides, overhead, PowerPoint, etc.) Other: Describe: 6