CME Speaker Confirmation Form

CME Program Information
CME program *
Activity date Activity date * / MM / DD YYYY
Speaker Information
Name Name * First Last
Title *
Affiliation *
City *
State *
Email *
Phone Phone * - ### - ### ####
Presentation Details
Presentation title *
Learning objective(s) for participants

List at least one objective indicating what the physician learner should be able to DO as a result of the lecture or learning activity. Objective(s) should reflect participants’ learning (rather than what the speaker plans to accomplish). Performance-oriented learning objectives begin with verbs such as analyze, apply, assess, determine, differentiate, diagnose, evaluate, identify, manage, propose, recommend, relate, use or utilize.
Objective 1 *
Objective 2
Competencies addressed

The presentation should address at least one or two of the core competencies for Accreditation Council for Graduate Medical Education (ACGME) and Institute of Medicine (IOM). Please indicate the competencies addressed by your presentation as well as which competencies are primary and secondary.
ACGME core competencies *

ACGME core competencies Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice
Primary AGME competency *
Secondary AGME competency
IOM core competencies *

IOM core competencies Patient care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics
Primary IOM competency *
Secondary IOM competency
Permission for Presentation Telecasting, Streaming, and Electronic Posting

I understand and agree that my presentation, voice, image and/or likeness may be digitally recorded at the above CME Program Activity. While the presentation continues to be my intellectual property, I give permission for Macon & Joan Brock Virginia Health Sciences at Old Dominion University (VHS) to telecast, stream, post electronically, or use the recording for academic purposes only. Any further use will be permitted only after I have given specific written approval. I hereby certify that the use of my image and/or presentation does not, to the best of my knowledge, information, and belief, violate any federal or Virginia laws, rules, or regulations, or the rights of any other person or organization. I agree to hold VHS, its officers, directors, employees, affiliates, successors and assigns, from any and all liability from claims against VHS arising out of my presentation.
Please enter your name Please enter your name * First Last
Today's date Today's date * / MM / DD YYYY
Important Information
- - The presentation must be run from an VHS computer connected to our network to be broadcast. Please have your PPT presentation formatted for Windows and saved on a portable drive.
- - LCD projector, computer and laser pointer will be provided. If additional equipment is required please send your request to the CME Program Contact above.
- - If you have handouts to be copied for distribution, please send them to the CME Program Contact one week in advance.
- - If not using the VHS venue computer – you must arrive 30 minutes prior to the scheduled start time. Media Services will be on-hand to assist in setup and testing. All presentations should be in 16:9 aspect ratio, or widescreen, for the best viewing experience. Please send media files 48 hours ahead of time to Live@evms.edu. If media files are too large to email, navigate to SendIt.evms.edu and click Sign up here. Enter Live@evms.edu in Recipients, including the date, time and topic in the Message field. Email Live@evms.edu with questions regarding VHS audiovisual support/services or dial 757.446.0556.

CME Speaker Confirmation Form

CME Speaker Confirmation Form

CME Program Information

Speaker Information

Presentation Details

Learning objective(s) for participants

Competencies addressed

Permission for Presentation Telecasting, Streaming, and Electronic Posting

Important Information