Thank you for submitting a course proposal to be considered for inclusion in the 2020 ASN Annual Meeting Program. All Course Directors must submit a Financial Disclosure form prior to submitting their proposal. If you have not done so already, CLICK HERE to complete your disclosure. Please complete all fields and be as thorough as possible.

COURSE PROPOSAL APPLICATION

Please note: Course Directors must be current ASN members to have a proposal considered.

1. Name of Director: *
Affiliation: *
Cell Phone: *
Email: *
Assistant's Name: *
Assistant's Email: *

I am a current member of the ASN (Course Directors must be ASN members):

Title of Course: *
Description of Submitted Course (please limit to 2000 characters) *

OBJECTIVES: List 3 specific learning objectives for this CME activity. On the completion of this activity, participants will be able to:

Objective 1: *
Objective 2: *
Objective 3: *

Speaker 1:

Name:
Degree(s)
Appointment (Professor, Chair, Director, etc.):
Affiliation:
Email:

Speaker 2:

Appointment (Professor, Chair, Director, etc.):
Affiliation:
Type of Course *
Name:
Degree(s)
Email:
What modality will your Course address? (Check all that apply, press the Ctrl key to make multiple selections) *
Appointment (Professor, Chair, Director, etc.):

Speaker 4:

Affiliation:
Target Audience: *
Email:
Name:

At the end of the educational session, what will your learners have gained? (check all that apply - you must answer this question for your Course to be considered)

Speaker 9:

Educational Method (Check all that apply):

Please describe:
Degree(s):

Speaker 10:

Email:
Name:
What Desirable Physician Attribute(s) will your course address? (Select all that apply, press the Ctrl key to make multiple selections) *
Degree(s):

Speaker 5:

Appointment (Professor, Chair, Director, etc.):
Affiliation:
Name:
Appointment (Professor, Chair, Director, etc.):
Affiliation:
Degree(s):
Appointment (Professor, Chair, Director, etc.):
Affiliation:

Speaker 3:

Email:

Speaker 6:

Email:

Speaker 7:

Name:
Degree(s):
Appointment (Professor, Chair, Director, etc.):
Affiliation:
Email:
Why were the above educational methods chosen for this course? *

By checking "Yes" below, I agree to adhere to all deadlines and requirements as set forth by the ASN Executive Office and understand if I do not adhere to these deadlines and requirements I may be disqualified from presenting at the meeting:

Name:
What practice gap will this course address? (Practice gap is the difference between current and optimal practice) *
Degree(s):

Speaker 8:

How do you know the practice gap exists? (You must answer this question for your Course to be considered)




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