Dakota Diabetes Coalition Webinar Speaker Form

Please complete this form at your earliest convenience

Thank you for agreeing to be a speaker, and for your contribution to addressing diabetes in North Dakota

Name*
First Last
Email*
Speaker Qualifications*
Please list degree(s), institution(s) attended (please include City and State), and graduation year(s).
Bio*
Please provide a short bio for your introduction. Include training and employer/employment as it relates to your topic, as well as how you would like to be introduced as a speaker.
Upload a Resume/CV
Drop files here or
Accepted file types: pdf, doc, docx.
Webinar Information
Title of Presentation*
Date of Presentation*
Date Format: MM slash DD slash YYYY
Learning Objectives*
Please provide a minimum of three learning objectives.
Post Webinar Quiz Questions*
Please provide a minimum of five post webinar questions and answers.
Examples:
1. Post webinar quiz question?
a. First answer
b. Second answer
c. Third answer
d. fourth answer - Correct

2. Post webinar quiz true or false statement.
a. True - Correct
b. False
Teaching Strategies to be used*
Please check all that apply
- PowerPoint Presentation (Please provide the document 3 weeks prior to the presentation date)
- Polls
- Break-Out Sessions
- Instructional Games
- Other
For "Other" please provide detail*
Please provide a synopsis of the presentation and/or attach any reference materials below*
Presentation or Reference Materials
Drop files here or
Accepted file types: pdf, pptx, jpg, png, docx, xlsx.
Conflict of Interest Disclosure
The section is required. While an interest of affiliation with a corporate organization does not prevent you from making a presentation, the relationship must be made known to attendees.
Disclosure Statement*
I hereby certify that, to he best of my knowledge, no aspect of my current personal or professional circumstance places me in the position of having a conflict of interest with this presentation. I hereby certify that, to the best of my knowledge, neither I (including any member of my immediate family) have (has) received something of value from a commercial party related directly or indirectly to the subject of this presentation.
- The foregoing statements are true without exception.
- The foregoing statements are true expect as reported in detail below.
Detail*
Affiliations/Financial Interests
If you have relationships to repot, list the type(s) of relationship(s) and list organization below the category.
Grants/Research
Speakers Bureau
Consultant
Investments
Other Financial Interests
Digital Signature (Please enter your full name)*
By selecting the "I Accept" checkbox, you are signing this agreement electronically.*
I Accept
CAPTCHA

Dakota Diabetes Coalition Webinar Speaker Form

Please complete this form at your earliest convenience

Thank you for agreeing to be a speaker, and for your contribution to addressing diabetes in North Dakota

Webinar Information

Conflict of Interest Disclosure

Affiliations/Financial Interests