TSHP Speakers' Bureau Application
Please read the Application Documentation in advance of completing this application. Documentation is available here: http://tshp.org/uploads/3/4/2/0/34209843/application_documentation.pdf
Personal information provided will appear in promotional materials (excluding: mailing address, phone number, date of birth, and NABP information.)
Please provide the details of the activity.
Single Speaker Presentation
Co-Presenter 1 Email
Co-Presenter 2 Email
Yes, we will discuss.
No, we will NOT discuss
Short Session Description
LENGTH OF PRESENTATION IN MINUTES
Please indicate the equipment you require for your session.
Flip Chart & Markers
Audience Response/Survey System
No additional equipment needed
Theater (rows of chairs)
Classroom (rectangular tables & chairs)
Banquet (round tables & chairs)
CURRICULUM VITAE AND BIOGRAPHY
Submit a detailed CV and head-shot photo
and write a short biography below for inclusion in onsite faculty introduction and conference materials.
Please indicate below what method of presentation this session is appropriate for.
Live Presentation - Annual Seminar
Live Presentation - Local Chapter or Joint-Provider
Home-Study - TSHP Education Portal
Journal Article - Written material
My Local Area Only
No Live Presentation
Please indicate what (if any) preferences you have for honorarium or reimbursement. Negotiation of any compensation is between the requesting organization and the speaker. Please note: Those applying for Annual Seminar be subject to pre-determined honorarium and reimbursement policies.
Please describe your compensation preference
EDUCATIONAL NEEDS ASSESSMENT AND GAPS IN KNOWLEDGE
Faculty, along with TSHP, should identify the challenge or clarify the need (gaps in knowledge), the current state of pharmacy practice and the desired state of pharmacy practice. This should be evidence-based facts, rather than assumptions, and should be used to formulate what should be learned in order to move learners from their current state of practice to the desired state and assist in developing learning objectives. References and citations should be provided where appropriate.
DEVELOP AND CLARIFY THE NEED
What is the problem (potential or actual) that needs to be addressed? Or, what new process or procedure (current or future), recent change or expected changes are happening that will affect this group?
CURRENT STATE OF PRACTICE
What is the audience doing now that could or has led to this problem based on facts, rather than assumptions? Provide references or citations. Or, where is the audience currently in this skill, training, process, or procedural aspect?
DESIRED STATE OF PRACTICE
What should or could the audience be doing instead to solve or prevent this problem? Or, what information, skill or technique will the audience need to attain in order to implement this new process or procedure?
Has this program been presented previously? When and where?
Texas Society of Health-System Pharmacists (TSHP) will attempt to accredit your activity for pharmacists and pharmacy technicians either by following the ACPE accreditation standards that meet pharmacist requirements or by the PTCB continuing education standards that meet the certification guidelines for pharmacy technicians. Programs that benefit pharmacists and pharmacy technicians must have specific and separate learning objectives for each audience. If the continuing pharmacy education activity benefit only pharmacists, only pharmacy technicians or both, please complete the appropriate learning objective section below.
View the Determining Learning Objective document for details and resources.
Pharmacist Learning Objectives:
A minimum of three objectives is required. The majority of the objectives should be structured to meet identified educational gaps in knowledge that will move learners to a desired state of practice.
At the end of this activity, the pharmacist participant will be able to:
Pharmacist Learning Objectives
Technician Learning Objectives:
Note: Due to new PTCB rules technicians are no longer able to claim “P” credit. TSHP prefers all sessions applicable to technician education be accredited as a "T" as well.
Please complete a specific and separate set of objectives below.
A minimum of three objectives is required.
At the end of this activity, the participant will be able to:
Technician Learning Objectives:
Please indicate the appropriate activity type. Please note the learning assessment and feedback requirements and additional information needed based on the activity type.
– These activities primarily transmit knowledge (i.e. facts). The facts must be based on evidence as accepted in the literature by the health care professions.
Learning Assessment – Each activity in this category must include a multiple choice post-test (to be conducted electronically).
Assessment Feedback – The co-sponsor organization hosting the continuing educational activity or TSHP will provide participants with answers to post-test questions, along with an explanation of why the correct answers are the most appropriate.
– These activities are primarily constructed to apply the information learned in the time frame allotted. The information must be based on evidence as accepted in the literature by the health care professions.
Learning Assessment – Each activity in this category must include case studies structured to address application of the principles learned, or another hands-on approach.
Assessment Feedback – Feedback should be provided by faculty during delivery of the activity and include correct evaluation of case studies and rationale for correct responses.
Include a detailed abstract or outline of your proposed presentation. If available, also provide your presentation materials (i.e. Power Point Presentation, article, video, etc.)
Post-Test (Required for Home-Study Presentations)
ANYTHING ELSE WE NEED TO KNOW?
Active Learning Techniques
Activities must include active participation and involvement of the audience. Refer to the
Using Active Learning Techniques document
for appropriate teaching and learning methods based on the activity type.
Describe the Active Learning Techniques your session will include:
Accredited activities shall exhibit fair content balance, providing the audience with information of different perspectives from which to develop an informed professional opinion. Anyone who is in a position to control the content of an education activity must disclose all relevant financial relationships with any commercial interest. In addition, should it be determined that a conflict of interest exist as a result of a financial relationship you may have, this will need to be resolved prior to the activity. This information is necessary in order for us to be able to move to the next steps in planning this activity. If you refuse to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of this activity.
First, list the names of proprietary entities producing health care goods or services, consumed by, or used on patients, with the exemption of nonprofit or government organizations and non-health care-related companies with which you have, or have had, a relevant financial relationship within the past 12 months. Second, describe what you received (ex: salary, honorarium, etc.) You do not need to reveal how much you received. Third, describe your role.
What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options or other ownership interest, excluding diversifies mutual funds), or other financial benefits.
My role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board memberships and other activities.
I do not have any relevant financial relationship with any commercial interests.
No Financial Conflicts to Disclose.
Commercial Interest What I Received My Role
Example: Company "X" Honorarium Speaker
Commercial Interest 1:
What I Received:
Commercial Interest 2:
What I Received:
Commercial Interest 3:
What I Received:
Commercial Interest 4:
What I Received:
I, hereby, confirm all information as set forth above, as true and correct, and agree to deliver the activity as I have stated above in both a professional and educational manner. I also acknowledge and accept the compensation as outlined above as payment in full for my services. TSHP reserves the right to withhold reimbursement should an activity lend itself to a biased nature. Changes or alterations to this agreement are not valid unless initiated by both parties.
I further warrant and represent that this activity is my own original work, that I have the authority to enter into this agreement and that I am the sole copyright holder, or that I have obtained all necessary permissions or licenses from any persons or organizations whose material is included or used in my presentation.
I have read and agree to the statements above.
Type your full name here to serve as signature.
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