ACOEM Webinar Submission Form
ACOEM welcomes your ideas for future webinars! Webinars are currently conducted via Zoom, one hour in length, with the recommended day and time on Tuesdays at Noon CST. There is flexibility with the length (up to 1.5 hours), day and time. If you are interested in proposing a longer activity, please email us at webinars@acoem.org.
Primary Contact for Webinar:
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First Name
Last Name
Email:
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example@example.com
On behalf of (if applicable):
ACOEM Section or Component
If this is a section webinar, please indicate who can attend:
Section Members only
All ACOEM Members only
ACOEM Members (free) and ACOEM Non-members (TBD fee)
What date would you like to present this webinar (please do not promote any dates until confirmed by ACOEM):
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Month
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Day
Year
Date
What time would you like to present this webinar (Please use Central Time):
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2
3
4
5
6
7
8
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Are you requesting CME from ACOEM for this webinar?
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Yes
No
Webinar Title:
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Brief Description of Webinar Content (to be used in marketing):
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i.e. what makes this event unique?; what is appealing about this webinar?
Learning Objectives (need 2-3 objectives which should follow, "Upon completion of this activity, participants should be able to):
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For more information on writing learning objectives, please
click here
.
Identify the practice gaps that this webinar will address:
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Find more about practice gaps by visiting the ACCME website here: https://www.accme.org/resources/video-resources/accreditation-requirements/addressing-practice-gaps
Webinar Faculty
ACOEM staff will request disclosure forms and media release forms from all faculty once the webinar is confirmed.
Faculty 1: Name, Email, Credentials, Position
Faculty 2: Name, Email, Credentials, Position
Faculty 3: Name, Email, Credentials, Position
Faculty 4: Name, Email, Credentials, Position
Who is the target audience for this webinar?
OEM Physicians
Urgent Care Physicians
OEM Physician Assistants, Nurse Practitioners, Other Advanced Practitioners
Occupational Health Nurses
Industrial Hygienists
Safety Professionals
Which of the following formats/methods will you use to engage attendees?
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Q & A at end
Breakout rooms
Poll questions
Panel discussion
Add in video content
In the context of which of the following OEM competencies will this webinar be developed? Click all that apply.
Clinical Occupational and Environmental Medicine
OEM Related Law and Regulations
Environmental Health
Work Fitness and Disability Management
Toxicology
Hazard Recognition, Evaluation and Control
Disaster Preparedness and Emergency Management
Health and Productivity
Public Health, Surveillance, and Disease Prevention
OEM Related Management and Administration
Submit
Should be Empty: