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PCD Speaker Information Form

 

Please complete this speaker information form which will be used to register our courses for continuing education credit with IDCEC, AIA, EDAC and the Texas Nurses Association. 

You will be asked to provide the contact information for two references who can attest to your capability in instructional methods/design and learning processes as well as your ability to communicate content effectively and at an appropriate level for the desired audience. IDCEC representatives will contact all references. If they are unable to reach the references, approval will be delayed. References should come from individuals who have attended one of your previous presentations or someone outside your firm who can speak to the instructor’s presentation skills and professional background. References may not be from co-workers at the same company, university or firm.

Upon completion of this form you will be asked to upload a signed copy of the follow forms.  Click on each form to complete and sign if you have not done so already.

AIA CES Speaker Agreement
CNE Conflict of Interest Form
PCD-IS Volunteer Agreement Form

Thank you for taking the time to complete this speaker information form.

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Your name
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Company
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Position
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Your address
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Your phone number
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Your email
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Please list any courses taught in the past two years.  (If none, type NA)
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Please list your degrees.
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Please list your credentials (please spell out).
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Please list your areas of expertise as it relates to healthcare or design in which you have experience and would feel comfortable presenting at the PCD-IS. (Example: ED, OR, ambulatory care, LDR, Medical/Surgical, ICU, Pediatric Oncology, etc.)
 
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Please include your professional experience as it relates to continuing nursing education (if applicable).
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Please write a 50-100 word biography in the third person. 
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Reference Information

Please include the information for your references in this section. References should come from individuals who have attended one of your previous presentations or someone outside your firm who can speak to the instructor’s presentation skills and professional background. References may not be from co-workers at the same company, university or firm. Please do not use references from the Institute for Patient-Centered Design.
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Reference 1 Name (References may not be from co-workers at the same company, university or firm, or the Institute for Patient-Centered Design)

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Reference 1 Company

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Reference 1 Position

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Reference 1 Address

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Reference 1 Phone Number

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Reference 1 Email

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Reference 2 Name (References may not be from co-workers at the same company, university or firm, or the Institute for Patient-Centered Design)

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Reference 2 Company

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Reference 2 Position

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Reference 2 Address

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Reference 2 Phone Number

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Reference 2 Email

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Please upload a head-shot picture for us to use in marketing.
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Please Upload the signed AIA CES Speaker Agreement Form. (We will fill out the provider number and the course information.)
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Please upload the signed PCD-IS Volunteer Agreement.
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Please upload the signed CNE Conflict of Interest Form
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Thank You!

Thank you for taking the time to complete this speaker information form. Please submit this form using the button below.

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