Pennsylvania Physical Health/Behavioral Health Learning Community (PA PH/BH LC)

Webinar Proposal Form

PROPOSALS MUST BE SUBMITTED ELECTRONICALLY

Please type within the gray areas to complete the form. Boxes can be “selected” by double clicking on the box and changing the default value to “checked.”

Presentation Title:

All webinars are 60 minutes in length. Presenters should leave time for Q&A in each workshop.

The PA PH/BH LC is interested in webinars on the following topics related to physical health/behavioral health integration. Please note this list is not all-inclusive.

·  Promising practices

·  Integrated care models

·  Billing and finance issues

·  Treatment issues

·  Creating a culture of integration

·  Workforce issues

·  Operations and administration

·  Clinical issues

·  Health and wellness

Describe your Proposal

Overview – 500 words or less. This description will assist the selection committee in understanding your proposed topic and must provide sufficient depth to support the educational objectives requested below. It should be clear and specific.

Abstract: Description of your webinar in 50 words or less to be used in marketing announcements, if accepted. The PA PH/BH LC reserves the right to edit the submitted abstract for consistency of style.

Provide at least three measurable, learning objectives for this presentation.

1. 

2. 

3. 

Presenter Information: Provide name, degree, position, agency, address, telephone, and email for each presenter. Be sure to list the primary presenter to which all correspondence should be addressed first.

Primary Presenter:

Title:

Organization:

Street Address:

City, State, ZIP:

Phone:

Email:

Second Presenter:

Title:

Organization:

Street Address:

City, State, ZIP:

Phone:

Email:

Describe the background, knowledge, and expertise of each presenter, including previous experience and training/teaching on this topic. Do not insert vitae in response to this question. Credentialing bodies require a descriptive narrative response about the presenter(s).

EDUCATIONAL BACKGROUND:

Presenter Name / Degree / Institution (Name, City, State) / Major Area of Study / Year Completed

Have you presented via webinar before? Yes No

Do you have access to a web camera? Yes No

If yes, are you comfortable presenting via live video feed? (Choosing “no” will not affect the selection decision.) Yes No

Webinars are held the third Thursday of every month from 12:00 – 1:00 p.m. Please indicate which of the following dates you are available to present if your proposal is selected:

1/17/13

2/21/13

3/21/13

4/18/13

5/16/13

6/20/13

Statement of Vested Interest

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. Each presenter should read the following statement and mark the appropriate response. Vested interest statements are required by accrediting bodies.

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.

I have the following real or perceived conflicts of interest that relate to this presentation:

If my proposal is accepted, I agree to the following:

To schedule and participate in a practice webinar session prior to my assigned presentation date.

To send a copy of my Power Point presentation and any additional handouts at least two weeks prior to my assigned presentation date.

To develop a short three to five question post-test for attendees who request CEs.

All proposals must be submitted electronically via email to Jen Bankard, director of training and resource development (). Questions about proposal submissions may also be submitted to Ms. Bankard at any time prior to the deadline. Individuals will receive an electronic confirmation of proposal receipt. Decisions about inclusion of submissions will be made by November 16. All individuals will be notified of those decisions.

All proposals must be received by 5:00 p.m. November 12 to be considered.