The submission deadline for proposals for CE Presentations to be offered between
July 1 and December 30
is March 31 so that the CE committee can consider proposals at their April meeting, and be in contact with those who submitted proposals as soon after that as possible.
To submit a Proposal to Present a CE Program
• Select all of the text on these pages, copy, and paste them into your word processor. Adjust the margins or page layout for your own computer. Fill them out with all you want to say and then email the Proposal or print it out and postal mail it to the address at the bottom.
THE GREATER PITTSBURGH PSYCHOLOGICAL ASSOCIATION
APPLICATION TO PRESENT A CE PROGRAM
NAME of Main Contact or Presenter: _____________________________________________
TITLE OF PROGRAM (Please limit this to 20 words or fewer):
PROGRAM DESCRIPTION (In 60 words or fewer):
Please specify the proposed length of the program (Number of hours, half day, all day). _______________
I/We prefer to present our program on the following dates/day of the week: _________________
PROGRAM OBJECTIVES: Briefly state the objectives of the program in behavioral terms. Identify what specific skills or knowledge participants will have upon completion of the program. Please phrase your objectives in terms of specific outcomes. Please specify no more than 4 objectives.
Upon completion of this program, participants will:
1.
2.
3.
4.
AUDIO-VISUAL REQUIREMENTS:
[ ] flip chart and marker [ ] slide projector and screen [ ] overhead projector/screen
[ ] VCR and monitor [ ] whiteboard or blackboard [ ] screen/cart/A-V cord
ETHICAL CONSIDERATIONS:
A. Are you aware of any potential conflict of interest which would make it unethical for any of the following committee members to consider your proposal? If yes, please circle that person’s name and state the relationship or reason a conflict may exist: ___________________________________________________________________
Dr. Bill Fetter Dr. Susan Stollings Dr. Bruce Sorkin Dr. Steven Feinstein
Dr. Kit Gautier Dr. Tad Gorske Dr. Katie McCorkle
B. Are you presenting information about your own practice or research? __Yes __No
If “yes” then have you ensured the following:
1. That all confidentiality requirements have been maintained? __Yes __No
2. That all necessary permissions have been obtained? __Yes __No
If you have answered No to either of these questions, and you are presenting information about your own practice or research, please explain below or on a separate sheet:
Tax ID Number: __________________________
GPPA Member? __Yes __No
PRESENTER'S QUALIFICATIONS: Please list your qualifications which assure competence to present the material proposed. Include, publications, workshops given, or other relevant material. Do not replace this section with a CV. Extract from a CV the information which is relevant to this presentation. For multiple presenters, copy the headings above and add more space using your word processor or attach a separate sheet for each presenter.
By signing this form, the presenter attests that the information put forth is true to the best of his or her knowledge.
______________________________ ____________________
Presenter’s Signature Date
You can submit your proposal best by email to drkatie@drkatie.com but postal mail submissions, sent to Dr. Katie McCorkle, PO Box 730, Warrendale, PA 15095-0730 are acceptable also.