Workshop Proposal Form – Continuing Education Services

- Step 1 of 7

WORKSHOP ROLE

Which option best describes your role in this activity? *

Lead Presenter
Co-Presenter

PERSONAL INFORMATION

Prefix *

Dr.
Mr.
Mrs.
Miss

Name *

First

Last

Email *

Confirm Email

Phone *

Home Address

Address Line 1

City

State

Zip Code

BUSINESS INFORMATION

Business/Organization Name *

Business Address *

Address Line 1

City

State

Zip Code

Position/Title *

Job Description/Responsibilities *

EDUCATION INFORMATION

Please provide information on the degree(s) that are most relevant to your presentation.

Do you have a college degree? *

College/University/Institution *

Major Area of Study *

Degree *

Year Degree Awarded *

Add a 2nd Degree? *

College/University/Institution #2 *

Major Area of Study #2 *

Degree #2 *

Year Degree Awarded #2 *

PROFESSIONAL CREDENTIALS AND CERTIFICATIONS HELD BY YOU

Please select all current licenses and/or certifications that apply.

Administrator
Certified Prevention Specialist
Certified Rehabilitation Counselor
Education Administration
Licensed Professional Counselor
Masters Addictions Counselor
National Certified School Counselor
Licensed Certified Social Worker
Licensed Social Worker
Licensed Master Social Worker
Marriage and Family Therapist
Registered Nurse
Medical Doctor
Juris Doctor
Law Enforcement Officer
Teacher
Other
N/A

Please type your license/certifications here *

Would you like presenter credit for your presentation? *

ATTACHMENTS

Please attach a copy of your current: (1.) Resume' and/or Curriculum Vitae; (2.) Bio; and (3.) Clear, High-Definition Headshot.

File Upload (Curriculum Vitae or Resume') *

Click or drag a file to this area to upload.

WORD or PDF DOCUMENT ONLY

File Upload (Bio to be read as your introduction.) *

Click or drag a file to this area to upload.

WORD or PDF DOCUMENT ONLY

File Upload (Headshot to be used in conference marketing and promotions.) *

Click or drag a file to this area to upload.

High Resolution JPG or PNG Format ONLY

CONFLICT OF INTEREST DISCLOSURE

Have you received anything of value from a commercial supporter, which may have been perceived as direct or indirect interest in the subject(s) you are addressing in this educational activity? *

Please list the name of the commercial supporter(s): *

Please describe your relationship/role with the commercial supporter listed above (select all that apply) *

Speaker's Bureau
Consultant
Major Stockholder
Large Gift(s)
Shareholder
Grant/Research Support
No relationship
Other

Describe Other: *

Explain how conflict of interest will be resolved. *

Describe your professional experience and/or areas of expertise (including publications) related to the involvement in continuing education. What experience and/or expertise qualifies you to participate in your role for this activity? *

Identify how you took part in the planning and evaluation of your presentation: (select all that apply): *

Planned Objectives/Content
Planned Time Frame
Planned Teaching Strategies
Attended Committee Meetings
Reviewed Evaluation Summary
Will utilize evaluation to revise presentation as needed
Other

Please describe Other *

During your presentation, will you include discussion of any unlabeled or the investigational use of a product, device, or drug that has not been approved by the FDA? For the use being presented in this educational activity? *

Explain what you will discuss: *

You MUST disclose this information during your presentation. Select the method of disclosure: *

Handouts
Audio-Visuals
Verbal (during presentation)
Other

Describe Other *

How will conflict of interest be resolved? *

DETAILS FOR WORKSHOP #1

Focus Area. Please check all that apply. *

Graduated sanctions and incentives
Judicial interaction
Monitoring (e.g., drug testing) and supervision
Prevention
Recovery Support
Screening and assessment
Treatment and rehabilitation services
Youth Violence Prevention
Other

Type Other Focus Area Here *

Subject Matter. Please check all that apply. *

Behavioral Health
Co-Occurring Disorders
Cultural Competence
Diversity
Ethics
Gender Identification
HIV/AIDS
Mental Health
Opioids
Racial Ethnic Disparities
Resources
Restorative Justice
Strategies
Substance Use/Misuse
Violence
Other

Target Audience. Please check all that apply. *

Addiction Professionals
Administrators
Attorneys
Corrections Professionals
Counselors
General
Judges
Law Enforcement Professionals
Medical Professionals
Mental Health Professionals
Social Workers
Support Staff
Teachers/Educators
Treatment Service Professionals
Youth
Other

Workshop #1 Title *

***Must match the title on the agenda.

What date(s) are you available to present? YOU MAY HAVE ALREADY BEEN GIVEN YOUR PRESENTATION DATE. PLEASE SELECT THE APPROPRIATE ONE. CES reserves the right to adjust presentation dates and times where needed.

1st Choice *

2nd Choice

3rd Choice

Workshop #1 Summary *

Please provide a full, detailed summary of your entire presentation.
This summary will be utilized to prepare the best applications for continuing education credits.

Workshop #1 Description (100 words or less). In 3-5 sentences please provide a brief description of your presentation to be INCLUDED IN THE PROGRAM BOOK. *

This should be descriptive and exciting to attract attendees' attention.
This SHOULD NOT BE THE SAME AS YOUR WORKSHOP SUMMARY.

Will your workshop practice cultural awareness? *

Please explain how your presentation will practice cultural awareness. *

WORKSHOP #1 CITATIONS & REFERENCES

Provide 3 scholarly references or citations that were consulted during the creation of your presentation. This can be a book, news article, report, website, video interview, etc...

Citation/Reference #1 *

Citation/Reference #2 *

Citation/Reference #3 *

WORKSHOP #1 OUTLINE

Session Type *

Plenary Session
Breakout Session

Workshop #1 Duration *

Must be at least 60 minutes long. All sessions longer than 60 minutes must be in 30 minute intervals (ie, 90, 120, 150, 180, etc...)

Evaluation Tool *

Post Test
Attitude Scale
Structured Interview
Direct Observation of Skill Performance
Other

What method will be used to evaluate the effectiveness of this presentation?

Evaluation Category *

Learner Satisfaction
Knowledge
Skill and Attitude Change
Change in Practice
Other

Which category is most appropriate for your presentation

WORKSHOP #1 OBJECTIVES

Please provide 3 DIFFERENT learning objectives for your presentation. What do you want your audience to learn or be able to do after your presentation? Be SPECIFIC and BEGIN each objective with an action verb such as: DISCUSS, EXPLAIN, DEFINE, LIST, DEMONSTRATE, etc.

Objective #1 *

Objective #1 Supporting Information *

What information will you use to teach Objective #1.

Objective #1 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Objective #2 *

Objective #2 Supporting Information *

What information will you use to teach Objective #2.

Objective #2 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Objective #3 *

Objective #3 Supporting Information *

What information will you use to teach Objective #3.

Objective #3 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Would you like to submit information for a 2nd presentation? *

DETAILS FOR WORKSHOP #2

Focus Area. Please check all that apply. *

Screening and assessment
Judicial interaction
Monitoring (e.g., drug testing) and supervision
Prevention
Graduated sanctions and incentives
Recovery Support
Treatment and rehabilitation services
Youth Violence Prevention
Other

Type Other Focus Area Here *

Subject Matter. Please check all that apply. *

Behavioral Health
Co-Occurring Disorders
Cultural Competence
Diversity
Ethics
Gender Identification
HIV/AIDS
Mental Health
Opioids
Racial Ethnic Disparities
Resources
Restorative Justice
Strategies
Substance Use/Misuse
Violence
Other

Target Audience. Please check all that apply. *

Attorneys
Administrators
Corrections Professionals
Counselors
Judges
Law Enforcement Professionals
Social Workers
Teachers/Educators
Treatment Service Professionals
Youth
Other

Workshop #2 Title *

***Must match the title on the agenda.

1st Choice *

2nd Choice

3rd Choice

Workshop #2 Summary. *

Please provide a full, detailed summary of your entire presentation.
This will be utilized to prepare the best applications for continuing education credits.

Workshop Description (100 words or less). *

Should be descriptive and exciting to attract attendees' attention.
In 3-5 sentences please provide a brief description of your presentation to be INCLUDED IN THE PROGRAM BOOK.

Will your workshop practice cultural awareness? *

Please explain how your workshop will practice cultural awareness. *

WORKSHOP #2 CITATIONS & REFERENCES

Provide 3 scholarly references or citations that were consulted during the creation of your presentation. This can be a book, news article, report, website, video interview, etc...

Citation/Reference #1 *

Citation/Reference #2 *

Citation/Reference #3 *

WORKSHOP #2 OUTLINE

Session Type *

Plenary Session
Breakout Session

Workshop #2 Duration *

Must be at least 60 minutes long. All sessions longer than 60 minutes must be in 30 minute intervals (ie, 90, 120, 150, 180, etc...)

Evaluation Tool *

Post Test
Attitude Scale
Structured Interview
Direct Observation of Skill Performance
Other

What method will be used to evaluate the effectiveness of this presentation?

Evaluation Category *

Learner Satisfaction
Knowledge
Skill and Attitude Change
Change in Practice
Other

Which category is most appropriate for your presentation

WORKSHOP #2 OBJECTIVES

Objective #1 *

Objective #1 Supporting Information *

What information will you use to teach Objective #1.

Objective #1 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Objective #2 *

Objective #2 Supporting Information *

What information will you use to teach Objective #2.

Objective #2 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Objective #3 *

Objective #3 Supporting Information *

What information will you use to teach Objective #3.

Objective #3 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Would you like to submit information for a 3rd presentation? *

WORKSHOP #3 DETAILS

Focus Area. Please check all that apply. *

Screening and assessment
Judicial interaction
Monitoring (e.g., drug testing) and supervision
Prevention
Graduated sanctions and incentives
Recovery Support
Treatment and rehabilitation services
Youth Violence Prevention
Other

Type Other Focus Area Here *

Subject Matter. Please check all that apply. *

Behavioral Health
Co-Occurring Disorders
Cultural Competence
Diversity
Ethics
Gender Identification
HIV/AIDS
Mental Health
Opioids
Racial Ethnic Disparities
Resources
Restorative Justice
Strategies
Substance Use/Misuse
Violence
Other

Target Audience. Please check all that apply. *

Attorneys
Administrators
Corrections Professionals
Counselors
Judges
Law Enforcement Professionals
Social Workers
Teachers/Educators
Treatment Service Professionals
Youth
Other

Workshop #3 Title *

***Must match the title on the agenda.

1st Choice *

2nd Choice

3rd Choice

Workshop #3 Summary. *

Please provide a full, detailed summary of your entire presentation.
This will be utilized to prepare the best applications for continuing education credits.

Workshop #3 Description (100 words or less). *

Should be descriptive and exciting to attract attendees' attention.
In 3-5 sentences please provide a brief description of your presentation to be INCLUDED IN THE PROGRAM BOOK.

Will your workshop practice cultural awareness? *

Please explain how your presentation will practice cultural awareness. (copy) *

WORKSHOP #3 CITATIONS & REFERENCES

Provide 3 scholarly references or citations that were consulted during the creation of your presentation. This can be a book, news article, report, website, video interview, etc...

Citation/Reference #1 *

Citation/Reference #2 *

Citation/Reference #3 *

WORKSHOP #3 OUTLINE

Session Type *

Plenary Session
Breakout Session

Workshop #3 Duration *

Must be at least 60 minutes long. All sessions longer than 60 minutes must be in 30 minute intervals (ie, 90, 120, 150, 180, etc...)

Evaluation Tool *

Post Test
Attitude Scale
Structured Interview
Direct Observation of Skill Performance
Other

What method will be used to evaluate the effectiveness of this presentation?

Evaluation Category *

Learner Satisfaction
Knowledge
Skill and Attitude Change
Change in Practice
Other

Which category is most appropriate for your presentation

WORKSHOP #3 OBJECTIVES

Objective #1 *

Objective #1 Supporting Information *

What information will you use to teach Objective #1.

Objective #1 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Objective #2 *

Objective #2 Supporting Information *

What information will you use to teach Objective #2.

Objective #2 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other

Objective #3 *

Objective #3 Supporting Information *

What information will you use to teach Objective #3.

Objective #3 Teaching Strategies/Resources *

Lecture
Role Play
Graphics/Visuals/PowerPoint Presentation
Questions/Answers
Feedback
Group Work
Other