2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Thank you for your interest in developing a proposal for the 2016 ASHP Midyear Clinical Meeting in Las
Vegas, Nevada, December 4-8, 2016.
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Your proposal must be submitted no later than 11:59 p.m. (PST), Monday, February 1, 2016.
Review the Proposal Guidance General Criteria to see how the Educational Programing
Committee will evaluate each proposal.
NOTE: If your proposal is accepted for presentation, you must be a current full active member
of ASHP (non-pharmacists excluded) through the time of the presentation at the meeting.
To begin, either create a new account or login if you are returning to update a proposal.
Please note that the "Login Email" will be the address ASHP will use to contact you in regards to
your proposal.
Use this form to plan your session. To submit your proposal, all information on this form must be
entered into the online site at
Only proposals submitted online via the website will be considered for presentation.
SUBMITTER PROFILE
Please fill out the information completely as you would like it to appear in print – no nicknames or
abbreviations. Fields with an asterisk (*) are required.
*First:
Prefix /Salutation ( e.g., Mr. Ms. Dr. etc.):
Middle:
*Last:
Suffix (e.g., Jr, Sr.):
MAILING ADDRESS
*Address Line 1:
*City:
*State:
*Zip / Postal Code:
Address Line 2:
Province (outside USA):
Country (if not USA):
CONTACT INFORMATION
*E-Mail Address:
Cell Phone:
*Office Telephone:
Fax:
PROFESSIONAL INFORMATION
*Position Title
*City:
Province (outside of USA):
*Employer:
State (required if in USA):
Country (if not USA):
Degrees /credentials:
FASHP:
Yes
No:
© 2015, American Society of Health-System Pharmacists
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Tasks: You must complete ALL tasks to submit your proposal.
TASK 1: PROPOSAL
Proposal Title (required)
A proposal must have a short, specific presentation title (containing no abbreviations) that indicates the nature of
the presentation.
General Program Topic Category (Select ONE)
Select one topic area for your proposal. This helps to match your proposal to the appropriate reviewer.
Topic Category
Cardiology / Anticoagulation
Clinical Topics / Therapeutics
Clinical Services Management
Critical Care
Informatics / Technology
Law/ Regulatory / Accreditation
Leadership / Management
Emergency Medicine / Emergency Preparedness
Geriatrics
Infectious Disease
Investigational Drugs
IV Therapy / Infusion Devices
Nutrition
Oncology / Hematology
Pain Management / Palliative Care
Pediatrics
Pharmacokinetics
Precepting
Psych / Neurology
Safety / Quality
Research Outcomes/ Drug-Use Evaluation
Toxicology
Transplantation / Immunology
Technician Competencies / Development
Women’s Health
Submission Category (Select ONE)
Knowledge-based: Designed primarily for participants to acquire factual knowledge.
Application-based: Designed primarily for participants to apply the information learned in the
allotted timeframe.
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Practice Area
Use to categorize on Web. Select up to TWO (2) practice area(s). This helps attendees find sessions they want to
attend.
Ambulatory Care*
Clinical/Therapeutics*
Residents / New Practitioners*
Small/Rural*
Pediatrics*
Informatics/Tehnology
Law / Accreditation / Regulatory
Leadership / Management – including management of clinical services
Precepting
Professionalism e.g., publishing, career development, practice models, etc.
Safety /Quality
Students
Technicians
Practice Interests (select at least ONE)
If you selected “Ambulatory Care, Clinical/Therapeutics, Residents/New Practitioners, Pediatrics, or
Small/Rural” further define by selecting ONE below.
Cardiology / Anticoagulation
Complementary Alternative Medicine (herbals, etc.)
Critical Care
Chronic/ Managed Care
Drug Information
Emergency Medicine / Emergency Preparedness
General Clinical Practice
Geriatrics
Home Care
Infectious Diseases
Investigational Drugs
IV Fluids / IV Therapy
Nuclear Pharmacy
Nutrition Support
Oncology / Hematology
Operating Room Pharmacy
Pain Management / Palliative Care
Pharmacokinetics
Psych / Neurology
Research/ Outcomes / Drug-Use Evaluation
Toxicology
Transplant / Immunology
Women's Health
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Educational Level of Content (Select ONE)
General interest: level designation not applicable to this session.
Intermediate: Basic knowledge of the specific content area is suggested but, extensive
experience is not necessary.
Advanced: General working knowledge of the specific content area suggested, information will
be provided to expand current expertise.
Target Audience (Select ONE)
Pharmacist
Pharmacy Technician
Pharmacist and Pharmacy Technicians
Other (e.g., Physician, Physician Assistance, Nurse, Nurse Practitioner)
Specify:
Describe the practice gap(s) that this session will address: (Maximum 100 words)
A practice gap exists when what needs to happen in practice is not happening. (i.e. there is a problem that needs to
be fixed). What is the problem that you intend to fix through this educational session?
Description and Overall Purpose (Maximum 400 words)
Brief description and overall purpose of this educational session that will entice your audience to attend and set
realistic expectations of the content:
What supplemental educational materials (such as outlines, forms, background materials,
bibliographies, etc.) will you provide to be distributed to attendees in addition to copies of your
slides? (Maximum 200 words)
A good educational session provides the learner with more than just copies of slides. To make your session more
valuable to the attendees, what supplemental educational materials (such as practice examples, outlines, forms,
background materials, bibliographies, etc.) will you provide to be distributed to attendees (electronically) in
addition your slides?
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Briefly describe how you are going to 'wow' your audience:
(Maximum 200 words)
TASK 2: NEED ASSESSMENT DOCUMENTATION
* Needs Assessment Documentation: (Select at least 2 from the list below)
Expert Opinion
National Guidelines
Government / Regulatory Requirement
Peer-Reviewed Literature (List 2 citations)
Board /Re-Certification Requirements
New Technology / Methods
Needs Assessment Survey (ASHP or Other)
Other
Identify the name of expert, guideline, research, etc. for your needs assessment choices from above
(Maximum 60 words)
What does the expert, guideline, research or other says that supports the need. (Maximum 25 words)
TASK 3: LEARNING OBJECITVES
Provide learning objectives that are clear, measurable, and achievable.
You must have at least 3 learning objectives with corresponding active learning strategies and learning
assessment.
See Example: for an Application-based Session
Learning Objective:
Learning Assessment:
Given a description of a specific patient,
develop a medication regimen that reflects
application of the best evidence and current
guidelines.
Solution to the case study with evidencebased references and current guidelines
being applied.
Active Learning Strategy:
(Choice from list)
Interactive case study
Please Note: ACPE requires active learning and learning assessment for each session objective. Only
proposals with these elements will be considered by the Programming Committee.
Refer to the “Session Development Guide” for additional details. For more information on Active
Learning: http://www.ashp.org/forpresenters.
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
SESSION DEVELOPMENT GUIDE
The Session Development Guide will give you information on writing learning objectives, creating
instructional strategies, and developing mechanisms to assess leaning according to Activity Type.
Developing Learning Objectives according to Activity Type
Knowledge-Based Activity
Application-Based Activity
Designed primarily for participants to acquire factual
knowledge.
Sample of Appropriate Verbs:
Explain
Describe
List
Define
Identify
Summarize
Learning Objective Examples:
Designed primarily for participants to apply the information
learned in the allotted timeframe.
Sample of Appropriate Verbs:
Apply
Design
Develop Evaluate
Interpret
Recommend
Explain how to perform effective distribution and nondistribution activities in the operating room.
Recommend strategies for solving cases involving how to perform
effective distribution and non-distribution activites in the
operating room.
List ways clinical surveillance systems can provide cost
savings.
Describe leadership strategies, tactics, and critical
thinking skills needed in complex environments.
Learning Objective Examples:
Using a set of criteria, evaluate ways in which clinical surveillance
systems can provide cost savings in your institution.
Develop a personal action plan for recognizing and applying
leadership strategies, tactics, and critical thinking skills needed in
complex environments.
Matching Active Learning Strategies to Activity Type
Active Learning Strategies
Knowledge-Based Activity
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Lecture with questions
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Games and quizzes to practice recall
Demonstration
Example with practice
Interactive case study
Interactive scenario
Role play
Simulation
Application Exercises
Practice Exercises
Assessment of Learning and Assessment Feedback
Knowledge-Based Activity
Assessment of Learning
Assessment of Feedback
Must include assessment questions structured
to determine the recall of facts based on the
learning objectives. Techniques can be informal
such as audience response systems, color cards,
or the raising of hands.
Feedback may include the correct response to
questions. For incorrect responses,
communicate that a question was answered
incorrectly and provide rationale for the correct
Application-Based Activity
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Application-Based Activity
Must include case studies structured to
address application of the principles learned
based on the learning objectives.
Feedback may include the correct evaluation
of case studies. When responses are
incorrect, explain the rationale for the
correct responses.
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
response.
Learning Objective
(minimum 3 required)
learning Assessment
Active Learning Strategies
Select 1 – from list below
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2
3
4
5
Active Learning Strategy: (options to choose from online)
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Lecture with questions
Games and quizzes to practice recall
Demonstration
Examples with practice
Interactive Case Study
Interactive Scenario
Role play
Simulation
Application Exercises
Practice Exercises
TASK 4: ADDITIONAL REQUIRED INFORMATION
Planned in cooperation with: Is your program planned in cooperation with a group?
Check all that apply
None
ASHP Section of Ambulatory Care Practitioners
ASHP Section of Clinical Specialists and Scientists
ASHP Section of Inpatient Care Practitioners
ASHP Section of Pharmacy Informatics and Technology
ASHP Section of Pharmacy Practice Managers
ASHP New Practitioners Forum
ASHP Pharmacy Student Forum
Other (specify):
As a Pharmacist, I agree to have an active ASHP Membership if my proposal is accepted and continue
my membership through delivery of the program at the meeting. (Required)
I agree
I am not a pharmacist or pharmacy technician
If you are not a pharmacist or pharmacy technician and requesting an exception, please specify:
© 2015, American Society of Health-System Pharmacists
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Submitter Planning Experience (Maximum 400 words)
Experience in planning educational programs
Submitter Expertise and Qualification (Maximum 400 words)
Expertise / qualifications in the topics(s) you are proposing
* ASHP Member ID
If you are not an ASHP member, enter N/A or not applicable
TASK 5: LENGTH OF SESSION (Select only one choice)
ACPE credit is given in 15 minutes increments only. Shorter sessions are preferred by meeting
attendees. ACPE no longer allows partial attendance, in order to claim CE an attendee must stay for the
entire duration, thus, shorter sessions are desirable.
If you selected Application-Based, your session must be at least 60 minutes.
15 minutes (maximum of 1 presenter)
30 minutes (maximum of 1 presenter)
45 minutes (maximum of 1 presenter)
1 hour (maximum of 2 presenters)
1 hour 15 minutes (maximum of 2 presenters)
1 hour 30 minutes (maximum of 3 presenters)
1 hour 45 minutes (maximum of 3 presenters)
2 hours (maximum of 4 presenters)
2 hours 30 minutes (maximum of 4 presenters)
Other length
Specify (maximum 60 words):
TASK 6: SESSION OUTLINE
Prepare a proposed outline of your educational session, include a description and proposed speaker for
each topic and include the time allocated to each topic.
*It is understood that the speakers you list are those you will pursue upon acceptance of this
proposal. Do not confirm your speakers at this time.
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Online you will need to follow the instructions to create a table with 4 columns and a minimum of 5
rows to enter your session outline.
Topic
Description
Proposed Speaker
Time Allotted
TASK 7: PROPOSED PRESENTERS
Add the list of presenters for your proposal. *It is understood that the speakers you list are those you
will pursue upon acceptance of this proposal. Do not confirm your speakers at this time.
Please add yourself as the first presenter.
Online the system will automatically add the submitter as the first presenter along with his information.
Proposed Presenter 1 (Submitter)
Name:
Degree(s) and/or Credentials(s):
Position title:
Employer:
City:
Mailing Address:
State/Province:
Phone:
Country:
Email:
Experience in planning educational program. (Maximum 400 words)
Expertise/qualification in the topic(s) you are proposing (Maximum 400 words)
Proposed Presenter 2
Name:
Position title:
City:
Mailing Address:
Degree(s) and/or Credentials(s):
Employer:
State/Province:
Country:
Phone:
Email:
Experience in planning educational program. (Maximum 400 words)
Expertise/qualification in the topic(s) you are proposing (Maximum 400 words)
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
Proposed Presenter 3
Name:
Position title:
City:
Mailing Address:
Degree(s) and/or Credentials(s):
Employer:
State/Province:
Country:
Phone:
Email:
Experience in planning educational program. (Maximum 400 words)
Expertise/qualification in the topic(s) you are proposing. (Maximum 400 words)
Proposed Presenter 4
Name:
Position title:
City:
Mailing Address:
Degree(s) and/or Credentials(s):
Employer:
State/Province:
Country:
Phone:
Email:
Experience in planning educational program. (Maximum 400 words)
Expertise/qualification in the topic(s) you are proposing (Maximum 400 words)
Proposed Presenter 5
Name:
Position title:
City:
Mailing Address:
Degree(s) and/or Credentials(s):
Employer:
State/Province:
Country:
Phone:
Email:
Experience in planning educational program. (Maximum 400 words)
Expertise/qualification in the topic(s) you are proposing (Maximum 400 words)
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
TASK 8: FINANCIAL RELATIONSHIP DISCLOSURES
ASHP requires that all prospective program faculty, committee members, and others in a position to
control content for continuing education activities, disclose all relevant financial relationships with
commercial entities whose products and/or services will be discussed during the session.
A "relevant financial relationship" exists if you (and/or your spouse/partner) are an employee,
consultant, clinical investigator, author, shareholder, board member, speaker, or receive research
support or other financial benefit in any amount, from any organization whose products and/or services
are to be discussed in the session. You must disclose all such relationships that have existed within the
past 12 months.
The financial relationship information you give here will be for all sessions you are participating in at this
meeting. Prospective faculty members who refuse or fail to disclose their information in a timely
manner will be disqualified from participation in the sessions.
Have you or your spouse/partner had a relevant financial relationship in any amount in the past 12
months with commercial entities whose product and/or services will be discussed during the session?
Yes
No
Has your institution/employer had a significant financial relationship ($5,000 or more) in the past 12
months with commercial entities whose product and/or services will be discussed during the session?
Yes
No
If yes to either of the above, please complete below:
Commercial Entity
Relationship:
Author, Board Member, Consultant, Employee,
Research Grant Recipient, Speaker’s Bureau,
Stockholder, Other (please specify)
Does this relationship
still exist?
(yes or no)
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2016 ASHP MIDYEAR CLINICAL MEETING
EDUCATIONAL PROPOSAL (RFP) WORKSHEET
TASK 9: AGREEMENT TO CONFLICT OF INTEREST TERMS
Please indicate that you agree to adhere to the conflict of interest terms in order to present by selecting
the checkbox below. Then enter your name on the line provided and select "Submit Agreement".
The content and/or presentation will
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be aligned with the interest of the public;
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represent best and complete evidence;
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be fair and balanced;
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have any included published sources easily identifiable;
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use generic names; if trades names are used, then all trade names for a particular entity (drug, device,
technology) must be included;
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promote quality improvements in health care and will not promote a specific propriety business interested of
a commercial interest.
I have not and will not accept any honoraria, additional payments, or reimbursements beyond that which has been
agreed upon directly with ASHP.
I am permitted to express my personal and professional opinions based on my experience and/or my analysis of the
evidence.
I understand that ASHP will peer-review my slides and/or handout.
I understand that a disclosure will be included in a slide inserted into my presentation, an announcement at the
beginning of the session, and printed in the on-site program book.
Yes , I agree to the conflict of interest terms
Remember:
 Paper copies will not be accepted. Use the form to plan your session
 The online submission site will contain all the information, but the order maybe slightly different
 Use the link for the RFP submission site posted on the www.ashp.org/Get_involved
© 2015, American Society of Health-System Pharmacists
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