CALL FOR PRESENTATIONS
2014 NATIONAL CONFERENCE
DISNEYLAND, ANAHEIM CA
JUNE 7 – 11, 2014
SUBMISSION DEADLINE OCTOBER 31, 2013
Company
(please print clearly)
First Name
Last Name
Title
Address
City
Phone
State
Zip
Email
DETAILS OF REQUIREMENTS:
 Educational Session Proposals must be 60-90 minutes in duration

Title of Program: (Program must be designed for the Nurse Administrator or Administrator in
the Long Term Care Continuum) (Please check the appropriate category for your program)

Will program fit a tract for:
1) “New” Nurse Administrator _____
2) “Seasoned” Nurse Administrator _____
3) Assisted Living Nurse Administrator _____ 4) ALL _____

Examples of past presenting experience must be submitted (dates and titles of programs
presented in the last 2 years) Attach separate page please.

All sessions must be commercial free
Each selected speaker MUST submit a speaker packet as required for accreditation of
continuing education hours and NAB credits or your Call for Presentation will not be
considered.
PLEASE SUBMIT ALL REQUIRED DOCUMENTATION WITH APPLICATION
You will receive one complimentary conference registration per session if your proposal is selected.
NADONA/LTC reserves the right to accept or deny application
Mail to: NADONA/LTC, Reed Hartman Tower, 11353 Reed Hartman Highway, Suite 210, Cincinnati, OH 45241
or email to: speaker@nadona.org
Questions? Call NADONA/LTC at 1-800-222-0539 or email speaker@nadona.org
NADONA/LTC
Biographical and Conflict of Interest Form
2014 Criteria
Title of Educational Activity:
AP-BIO/COI
Education Activity Date:
Role in Educational Activity: (Check all that apply)
Must include Bibliography as separate attachment
w/ references (List name of Article and URL location)
for consideration
Planning Committee Member
Faculty/Presenter/Author
Content Reviewer
Other – Describe:
Section 1: Demographic Data
Name with Credentials/Degrees: ________________________________________________________
If RN, Nursing Degree(s):
AD
Diploma
BSN
Masters
Doctorate
Address: ___________________________________________________________________________
Phone Number: ______________________________
Email Address: ________________________
Current Employer and Position/Title: _____________________________________________________
Section 2: Expertise - Planning Committee
If a planning committee member, select area of expertise specific to the educational activity listed above:
Nurse Planner (responsible for ensuring adherence to ANCC Accreditation criteria)
Content Expert
Other
Please describe expertise and years of training specific to the educational activity listed above. (If the description
of expertise does not provide adequate information, the Nurse Planner may request additional documentation.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Section 3: Expertise - Presenter/Faculty/Author/Content Reviewer
An "X" on this line identifies the expertise information the same as listed above.
Please describe expertise and years of training specific to the educational activity listed above. (If the description of
expertise does not provide adequate information, the Nurse Planner may request additional documentation.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Section 4: Conflict of Interest
The potential for conflicts of interest exists when an individual has the ability to control or influence the content
of an educational activity and has a financial relationship with a commercial interest,* the products or services
of which are pertinent to the content of the educational activity (see Figure 6). The Nurse Planner is responsible
for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential
conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse
Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as
Nurse Planner for the educational activity.
*Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing
healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an
entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on
patients.
Commercial Interest Organizations are ineligible for accreditation.
An organization is NOT a Commercial Interest Organization* if it is:













A government entity;
A non-profit (503(c)) organization;
A provider of clinical services directly to patients, including but not limited to hospitals, health
care agencies and independent health care practitioners;
An entity the sole purpose of which is to improve or support the delivery of health care to
patients, including but not limited to providers or developers of electronic health information
systems, database systems, and quality improvement systems;
A non-healthcare related entity whose primary mission is not producing, marketing or selling or
distributing health care goods or services consumed by or used on patients.
Liability insurance providers
Health insurance providers
Group medical practices
Acute care hospitals (for profit and not for profit)
Rehabilitation centers (for profit and not for profit)
Nursing homes (for profit and not for profit)
Blood banks
Diagnostic laboratories
(*Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial
Support, August 2007 (www.accme.org) - ANCC’s definition is intended to ensure compliance with Food and
Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency
with the ACCME definition)
All individuals who have the ability to control or influence the content of an educational activity must disclose
all relevant relationships** with any commercial interest, including but not limited to members of the Planning
Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to
the learners during the time when the relationship is in effect and for 12 months afterward. All information
disclosed must be shared with the participants/learners prior to the start of the educational activity.
**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or
services of the commercial interest are related to the content of the educational activity.
 Relationships with any commercial interest of the individual’s spouse/partner may be relevant
relationships and must be reported, evaluated, and resolved.

Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving
a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and
stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly
or indirectly from the commercial interest.

Financial benefits may be associated with employment, management positions, independent contractor
relationships, other contractual relationships, consulting, speaking, teaching, membership on an
advisory committee or review panel, board membership, and other activities from which remuneration
is received or expected from the commercial interest.
Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?
Yes
No
If yes, please complete the table below for all actual, potential or perceived conflicts of interest**:
Check all that
apply
Category
Description
Salary
Royalty
Stock
Speakers Bureau
Consultant
Other
* *All conflicts of interest, including potential ones, must be resolved prior to the planning,
evaluation of the continuing nursing education activity.
implementation, or
Section 5: Conflict Resolution (to be completed by Nurse Planner)
A. Procedures used to resolve conflict of interest or potential bias if applicable for this activity:
Not applicable since no conflict of interest.
Removed individual, with conflict of interest, from participating in all parts of the educational activity.
Revised the role of the individual with conflict of interest so that the relationship is no longer
educational activity.
Not awarding contact hours for a portion or all of the educational activity.
relevant to the
Undertaking review of the educational activity by a content reviewer to evaluate for potential bias,
balance in presentation, evidence-based content or other indicators of integrity, and absence of
bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation.
Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in
presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant
feedback to evaluate for commercial bias in the activity.
Other - Describe:
Section 6: Statement of Understanding
An “X” in the box below serves as the electronic signature of the individual completing this
Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.
Electronic Signature (Required)
Date ___________________________
_______________________________________________________________________________
Completed By: Name and Credentials
Nurse Planner Signature (*If form is for the activity Nurse Planner, an individual other than the
Nurse Planner must review and sign).
An “X” in the box below serves as the electronic signature of the Nurse Planner reviewing the content of
this Biographical/Conflict of Interest Form.
Electronic Signature (Required)
______________________________________________
Completed By: Name and Credentials
_______________
Date
Speaker Travel and Onsite Profile
In order to get in touch with you prior to your workshop please make the following information
available to us:
Name/Title: ______________________________________________________________________
Cell phone number: ________________
E-mail address: _________________________________
Presentation title: __________________________________________________________________
Date Arriving: _____________________ Airline/Flight Number: ___________________
Emergency Contact Person: _________________________________ Number: ________________
Please come to the convention center to NADONA registration area, to sign-in at least two hours prior
to the start of your workshop. There will be a speaker- ready room available for your convenience.
Please let us know if you intend to use the ready room so that we may reserve the time for your use.
When you check in the staff at speaker registration will assist you with your room location.
Our emergency contact information in case of flight delay or other unforeseen emergency:
Layne Oliff
908-403-6035 cell
layneo@maturehealth.com
Dan Raimonda
732-241-6729 cell
draimonda@maturehealth.com
Sherrie Dornberger
856-449-1636 cell
Bzynurse1@aol.com
APPENDIX A
Continuing Education Review Committee
Suggested Guidelines for Writing Learning Objectives
Clear and measurable behavioral learning objectives are a frequent stumbling block for program planners. You
may find these suggested guidelines helpful in writing learning objectives for your CE activity.
Learning objectives: specify what the learner will do to demonstrate the information learned (indicated by
specific verb), address one specific area of learning and should be stated in measurable terms.
An example of a clear and measurable learning objective: At the end of this activity, the learner will be able
to: "List two non-steroidal, anti-inflammatory agents used in the treatment of rheumatoid arthritis". A
learning objective is measurable when the learner can perform a task (list) identified in the learning objective.
Include only one measurable/action verb per objective.
An example of an immeasurable objective: At the end of this activity, the learner will be able to: "Increase
his/her knowledge of anti-inflammatory agents used in the treatment of arthritis." "Increase knowledge"
cannot be directly demonstrated, therefore is not a measurable objective. Likewise “understand” is not a
measurable verb – do not use this verb!!!
It may help to ask: 1) What do you want the learners to accomplish/learn?; 2) How will the learners demonstrate
that the desired information has been learned?; and, 3) What verb (see samples listed below) will you use in the
objective to indicate what the learner will do to demonstrate information learned?
Use an action verb. The verb should correspond with what opportunities are given for the learners to
demonstrate the newly learned information. For example, if your objective contains the verb discuss, then there
must be opportunities for the learner to discuss (one of your teaching methods must include "discussion").
Specific verbs correspond with the six levels of learning identified by Bloom. The table below contains a list of
the six levels of learning with some of their accompanying verbs—used when writing learning objectives. We
hope this list is helpful to you.
Knowledge
(to recall
facts)
Cite
Count
Define
Identify
Label
List
Name
Outline
Read
Recall
Recite
Recognize
Relate
Repeat
Select
State
Tell
Write
Comprehension Application
(to understand) (to apply
concepts/
demo skills)
Associate
Apply
Classify
Complete
Contrast
Demonstrate
Describe
Illustrate
Discuss
Manipulate
Distinguish
Operate
Explain
Perform
Give examples
Practice
Interpret
Predict
Locate
Relate
Predict
Report
Report
Restate
Restate
Review
Review
Translate
Use
Utilize
Analysis
(use info/make
connections)
Synthesis
(formulation)
Evaluation
(judgment)
Analyze
Appraise
Compare
Contrast Criticize
Debate
Detect
Diagram
Differentiate
Distinguish
Examine
Infer
Inspect
Question
Separate
Summarize
Arrange
Collect
Compose
Construct
Create
Design
Detect
Formulate
Generalize
Integrate
Manage
Organize
Plan
Prepare
Propose
Provide
Appraise
Assess
Choose
Critique
Determine
Differentiate
Estimate
Evaluate
Judge
Measure
Rate
Recommend
Revise
Select
NADONA/LTC
Educational Planning Table – Live (2014 criteria)
Title of Activity: ____________________________________________________________________________________________________________
Identified Gap(s): ____________________________________________________________________________________________________________
Description of current state:_________________________________________________________________________________________________
Description of desired/achievable state: _______________________________________________________________________________________
Gap to be addressed by this activity:
Knowledge
Skills
Practice
Other: Describe_________________________________________________
Purpose: (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to…..”
CONTENT
OBJECTIVES
List learner’s objectives in
behavioral terms
(Topics)
Provide an outline of the content for
each objective. It must be more than a
restatement of the objective.
TIME
FRAME
PRESENTER
State the time
frame for each
objective
List the Faculty for each
objective.
TEACHING METHODS
Describe the teaching
methods, strategies,
materials & resources for
each objective
1.
2.
3.
List the evidence-based references used for developing this educational activity:
Note: Time spent evaluating the learning activity may be included in the total time when calculating contact hours.
Total Minutes ____ divided by 60 = _____ contact hour(s)
______________________________________________________
Completed By: Name and Credentials
Rev. 07/31/2013
2014 - Live
__________________________________
Date
NADONA/LTC Educational Planning Table