2012 Teen Pregnancy Institute: Call for Presenters Form

Section 1: Contact Information

Name:

Title:

Agency/Organization:

Address:

City: State: Zip: _____

Phone: Fax:

Email:

Website:

Section 2: Workshop Details

Workshop Title/Topic:

Workshop Description (2–3 sentences, OR if you wish to be considered to develop a presentation, please give your areas of expertise. You also may attach additional information to this form.):

______

Intended Audience (please check all that apply):

______General Youth ______Mid-Level (2-4 years of experience)

Services Community

______Direct Services ______Advanced Professionals (5-9 years of experience)

______Entry Level (0-1 years of ______Senior Professionals (10+ years of

experience) experience)

______Program Managers

Expected Learning Outcomes for Participants:

1.

2.

3.

Have you presented at the Teen Pregnancy Institute in the past? ___Yes ___ No

If so, in which year? ______

What was the title/topic of your workshop? ______

If your presentation is not selected for the 2012 Institute, would you like the Massachusetts Alliance on Teen Pregnancy to consider your presentation for a future event or training? ___Yes ___ No

Would you be willing to make a tax-deductible donation of your presentation time to the Alliance? The Alliance would be happy to provide you with a receipt for your in-kind services. ____Yes ____No

Section 3: Attachments

In order for the MATP to offer continuing education credits to our participants, please attach the following documents;

1)  Current resume

2)  An outline of your presentation

3)  A list of at least 3 books or articles of reference from the presentation bibliography

4)  Enclosed conflict of interest disclosure

Please complete this form and send to Catherine Hummel, Prevention Associate, at by July 25, 2012.

Conflict of Interest Disclosure

Continuing Education activities are intended to serve the public interest. To this end it is the policy of the Massachusetts Alliance on Teen Pregnancy that all its educational programs are balanced, scientifically rigorous, objective and independent of commercial influence. The purpose of this form is to identify and resolve all potential conflicts of interests that arise from financial relationship with any commercial* or proprietary entity that produces healthcare-related products and/or services relevant to the content you are planning, developing, and presenting for this activity. This includes any financial relationships active within the last 12 months, as well as known financial relationships of your spouse or partner.

Name: ______

Role in Activity: Content Expert/Presenter

Title of Presentation:______

Check one of the options below on behalf of yourself and your spouse/partner:

___ We have no financial relationships with a commercial entity producing healthcare-related products and/or services.

___ The commercial entities with which we have relationships do not produce healthcare-related products or services relevant to the content I am planning, developing, or presenting for this activity.

___ We disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am planning, developing, or presenting:

Company / Type of Relationship** / Content Area (if applicable)

Attach an additional sheet if you need more room

*For the purposes of this form, do not consider an entity which provides clinical services directly to patients to be a commercial entity.

**Type of relationship may include full or part time employment; status as an independent contractor, consultant, research or other grant recipient, paid speaker or teacher; membership on advisory committees or review panel; ownership interest (product royalty/licensing fees, owning stock, shares, etc); or any other financial relationship.

Signature: ______Date: ______