Speaker Proposal Form

If you wish to make a presentation proposal, please complete and submit the following form in its entirety, as only complete forms will be considered. It is our policy to review all completed applications and file them for consideration on appropriate programs. THA requires speakers to provide information in an educational, non-commercial, non-self-promotional manner.

Submitted by:
Name:
Title:
Company:
THA Corporate Sponsor:
HealthShare Endorsed Company:
THA Member:
*Phone: -  -  EXT
Email:

Presenter:
Name:
Company:
Title:
Credentials:
Address:
City:
State:
Postal/Zip Code:
Country:
*Phone: -  -  EXT
Fax: -  -
Email:

Co-Presenter	Phone	Fax	E-mail
1.		- -
2.		- -
3.		- -

Speaking Experience
Specify three recent speaking experiences and provide following information for each:

Topic	Date	Location	Contact Name	Contact Number	Contact Email
1.				- - EXT
2.				- - EXT
3.				- - EXT

Proposed Presentation Title:

Length of Presentation:

Description of Presentation: (100 words or less)

*Type of Presentation: On-site Distance Learning:Webinar/Audioconference
Recording/ Self-paced

Knowledge Level of Presentation:

*Introductory (Assumes the participant has little or no knowledge of the areas covered)
Intermediate (Ideal for a participant with general knowledge of the literature and professional practice within the areas covered)
Advanced (Developed for the participant who has a thorough knowledge of the literature and professional practice of the content covered)

Target Audience:

Governing Boards	Director/Department Head
CEO	Senior Administrative Staff
CNO (Chief Nursing Officer)	Physicians
CFO	Nurses
Other (please list)

Learning Objectives:
(Complete this sentence, “At the completion of the presentation, participants will be able to…”) Examples: (1)Identify certain aspects of data handling and confidentiality that should be addressed by contractual provisions or (2) Recognize the importance of the service level agreement (SLA) to ensure minimum performance levels and limit liability for the impact of third-party actions, and points at which an SLA may be suspended

1.
2.
3.

Attach sheet to list additional learning objectives:

Additional Comments:

*Attach your resume or curriculum vitae:

* Required Fields

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