Invited Speaker Course Details Form

Lead Presenter Information
LEAD PRESENTER:*
First Last
ADDRESS:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
DAYTIME PHONE*
ALTERNATE PHONE:
EMAIL:*
LEAD PRESENTER BIO:*
Please Be Brief, Include Your Highest Educational Degree and Credentials and Write in 3rd Person.
FINANCIAL & NON-FINANCIAL DISCLOSURES:*
Please identify all financial and non-financial relationships/conflicts that exist regarding your presentation content.
- I Have No Financial & No Non-financial Relationships to Disclose
- Salary/Honorarium/Royalties/Commission Received
- Consulting Fee Received
- Employment Conflict
- Intellectual Property Rights (Trademark or Copyright)
- Publication Rights
- Patent on Technology or Equipment
SPECIFY/DEFINE YOUR RELEVANT FINANCIAL RELATIONSHIPS:*
SPECIFY/DEFINE YOUR RELEVANT NON-FINANCIAL RELATIONSHIPS:*
Presentation Details
Content should be evidence-based and identified as beneficial to professionals in Speech and/or Audiology or related fields.

Resources for choosing quality content can be found at: https://www.asha.org/ce/for-providers/EBCETutorialIntro/
PRESENTATION TITLE:*
Choose a title that clearly informs attendees of your content but is 100 characters or less.
CONTENT INSTRUCTIONAL LEVEL:*
Indicate the level of instruction being presented as it applies to the majority of your presentation.

Definitions for levels can be found at: https://www.asha.org/CEFind/Understanding-Continuing-Education-Terminology/
- Introductory
- Intermediate
- Advanced
DOES YOUR CONTENT FOCUS EXCLUSIVELY ON ONE SPECIFIC BRAND, PRODUCT OR THERAPY PROCESS?*
- Yes
- No
PLEASE CLARIFY/EXPLAIN THE EXCLUSIVITY OF YOUR CONTENT:*
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CONTENT FOCUS:*
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TOPIC AREA(S):*
Select All That Apply
- AAC
- Acquired Neuro
- Autism Spectrum Disorders (ASD)
- Audiology
- Child Lang/Literacy
- Cultural/Linguistic Diversity (CLD)
- Dysphagia
- Fluency
- Speech/Sound Disorders
- Voice
- Ethics
- Supervision
- Leadership
- Billing/Coding
- Interprofessional Content
- Innovations/Technological Advancements
PRESENTATION CONTENT ABSTRACT:*
Please provide a summary (50 words max) of your presention content for promotion and CE approval purposes.
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PRESENTATION LENGTH:*
- A 1.5 hr Presentation
- A 2 hr Presentation
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TIME ORDERED AGENDA:*
Please indicate a break down of your content to fill the course length you indicated above. Courses will not contain any break times within.
Time Content Covered
LEARNER OUTCOMES:
Provide 3 Measurable Outcomes an attendee can expect to obtain from hearing your presentation.

Visit: https://www.asha.org/ce/for-providers/Learner_outcomes/ for help with developing quality outcomes.

Start Each With "The Participant Will Be Able To"...
LEARNER OUTCOME #1*
LEARNER OUTCOME #2*
LEARNER OUTCOME #3*
Co-Presenter Information
DO YOU HAVE ANY CO-PRESENTERS/CO-AUTHORS?*
Yes
No
CO-PRESENTER/CO-AUTHOR:*
Please List All
Name Brief Co-Presenter Bio (Write in 3rd Person, Include credentials and relevant experience/expertise to your topic area)
CO-PRESENTER DISCLOSURES:*
Please identify all financial and non-financial relationships/conflicts that exist for your Co-Presenter(s) regarding your presentation content.
There Are No Financial & No Non-financial Relationships to Disclose
Salary/Honorarium/Royalties/Commission Received
Consulting Fee Received
Employment Conflict
Intellectual Property Rights (Trademark or Copyright)
Publication Rights
Patent on Technology or Equipment
CO-PRESENTER(S) FINANCIAL RELATIONSHIPS:*
Specify/Define the Relevant Financial relationships that exists for your copresenter(s)
CO-PRESENTER(S) NON-FINANCIAL RELATIONSHIPS:*
Specify/Define the Relevant Non-Financial relationships that exists for your copresenter(s)
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Presentation Space
Presentation rooms will be equipped with an LCD Projector & Screen, Room Audio, 1 Podium and 1 Wireless Lavaliere Mic. All meeting rooms are equipped with private event wifi.

You are responsible for bringing your own computer or tablet and any necessary HDMI or VGA adaptor your device requires to connect to a standard projector.
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ADDITIONAL NEEDS:
Please indicate if your presentation requires additional table space or if you will be bringing equipment that requires floor space.
Acknowledgements & Commitments
Commitment to Present*
My completion of this submission affirms that I am committed to present content for the OSLHA Learning Academy as agreed upon in writing by email. I acknowledge that promotional and financial efforts will be spent on advertising my presentation to registrants and therefore, agree to make accommodations through a replacement presenter in the event I am unable to fulfill my speaking commitment for any reason.
I Acknowledge and Agree
Contents & Disclosures*
I attest that I have read and agree to the terms outlined in the Presenter Author Agreement:
(https://www.ohioslha.org/oslha-ce2021/speakersla/authoragree/)
I Acknowledge and Agree
Handouts*
I understand I will be responsible for providing OSLHA with (8) post-session questions/answers, my prerecorded session & handouts electronically by the agreed upon deadline, deadline reminders appear on the speaker webpage.
I Acknowledge and Agree
Additional Details
Headshot Photo (Full color)*
Upload a high quality, high resolution, color, headshot photo of each presenter for use on the OSLHA Learning Academy and in event promotions.

Please do not use selfie photos.
Instead, have a colleague/family member take a photo by phone or camera from your shoulders up, from approx 4 ft away while you stand against a well-lit wall or plain background.
Accepted file types: jpg, png, gif, Max. file size: 100 MB.
ADDITIONAL DETAILS/COMMENTS
Use this space for any additional comments you have
Comments
This field is for validation purposes and should be left unchanged.

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Name	Brief Co-Presenter Bio (Write in 3rd Person, Include credentials and relevant experience/expertise to your topic area)

Time	Content Covered

Lead Presenter Information

Presentation Details

LEARNER OUTCOMES:

Co-Presenter Information

Presentation Space

Acknowledgements & Commitments

Additional Details