Wufoo
2022 PA EMS Conference Call for Speakers
Thank you for your interest in presenting at the 45th annual Pennsylvania EMS Conference.
This year's conference is being held "virtually", entirely online, from September 6 - 9, 2022. In addition, sessions will be recorded and made available for viewing after the "live" conference concludes.
Our goal is to craft a well rounded, informative, and engaging agenda for all of our conference attendees. Please assist us in making this goal a reality by providing complete information in the fields below.
Prospective speakers
must
complete the biographical data, conflict of interest statement, and session outline. A session outline should be completed for all sessions that you would like to have considered. Existing session outlines that include the requested information (objectives, content/topics, time frame, methods) may be uploaded in bulk.
Failure to provide all requested information will invalidate the proposal.
Deadline for submissions is Saturday, April 30, 2022
Please direct any questions to PEHSC at 717-795-0740 x104, or email conference@pehsc.org
This event is co-sponsored under a contract with the PA Department of Health.
Speaker Information
Name
*
First
Last
Degrees / Credentials
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
----
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Republic of North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Phone Number
*
###
-
###
-
####
Email
*
Organization Represented (if applicable)
Title (if applicable)
Please describe your expertise in the topic(s) that you are offering to present:
*
Please include a biographical statement to be used in conference promotional material (if selected)
*
Have you presented at other EMS related conferences?
*
Yes
No
Please list recent conferences and presentations:
If you have any honorarium or travel support requirements, please list them here:
Please attach a CV/resume
Please upload a high quality photograph to be used in conference promotional material (if selected)
Conflict of Interest Disclosure
Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity, and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty, or content specialist and/or his/her immediate family members have any relationships with sources of commercial support, e.g. pharmaceutical companies, biomedical device manufacturers, and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty, and content specialists participating in CE activities must disclose to the audience any of the following:
A. Relationship with companies who manufacture products used in the treatment of the subjects under discussion
B. Relationship between the planner, faculty, or content specialist and commercial supporter(s) of the activity
C. Intent to discuss unlabeled uses of a commercial product or an investigational use of a product not yet approved for this purpose.
All information disclosed must be shared with the audience either on the program handouts, advertising, and/or audiovisual presentation.
Is there a relationship with companies who manufacture products that will be discussed in your presentation(s)
*
Yes
No
Please list the type of relationship (choose all that apply)
Research support
Speaker's Bureau
Consultant
Shareholder
Large gift(s)
Other
Please list the name of the company:
Is there is discussion of unlabeled of off-brand uses?
*
Yes
No
By what means will you disclose this information during your presentation?
Verbal statement during the presentation
Information provided on handouts
Information provided in audiovisuals
Other
Session Description
Please describe the session(s) that you are proposing to present.
If you prefer (or if submitting for multiple sessions), you may also upload a document here that contains all of the requested information.
Upload session info (optional)
Session Title
Session Description
Session Length (in minutes)
Has this session even been approved for PA EMS Continuing Education Credit?
Yes
No
I don't know
PA DOH Course # (if known)
Credit Hours Awarded (if known)
Credit Category (if known)
Clinical
Other
EMSVO
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