Faculty CME Proposal Application

77th Annual Assembly & Exhibition
July 25 - 28, 2024
Sandestin Golf & Beach Resort
Destin, FL

Faculty CME Proposal Application

Please review all information before submitting your proposal. This information will be used in our records for communication and reimbursement purposes. If you have any questions, please contact the LAFP at 225.923.3313 for more information.

FACULTY CONTACT INFORMATION:

NOTE: The Academy is required by the Federal Government to issue Form #1099-MISC to each speaker that receives money from the Academy. This is related to honoraria only. Please make sure you have given us your Social Security Number. No additional amounts connected with the preparation of manuscripts or illustrative materials, including duplications, slides, etc., used in the speaker’s presentation will be paid.

First Name:*

Last Name:*

Designations (MD, DO, MPH, etc):*

Street Address:*

Street Address (line 2):

City:*

State*

Zip Code:*

Phone Number:*

Cell Phone Number:*

Fax Number:

Tax ID # or Social Security #:*

Date of Birth:*

Email Address:*

Will you have co-faculty?* Yes No

LAFP/AAFP Member:* Yes No

LAFP/AAFP ID #:

Description/Problem

Provide a description to the learner regarding the scope and focus of this education. Describe the problem you are solving and what the learner can expect to take away from this education.*

Direct Bearing on Patient Care

Provide a description regarding how this education has a direct bearing on patient care, or how it supports the physician’s role in patient care, or how it has a direct bearing on a physician’s ability to deliver patient care.*

Learning Objectives:

Describe the behavior in measurable terms that you, a faculty member, would expect to observe of the learner upon engaging with this session. This is not a list of how you plan to teach (i.e. “explain”, “describe”, “discuss”), but rather what you expect learners to be able to do when they return to practice. (e.g. Screen for eye conditions commonly associated with type 2 diabetes.) See Guidelines for Writing Learning Objectives.

Objective 1:

Objective 2:

Objective 3:

Objective 4:

Objective 5:

Recommended Practice Changes

Succinctly describe up to three recommended practice changes that you will challenge learners to implement as you summarize the key takeaways in the final slide of your presentation.

1.*

2.*

3.*

ACGME Core Competency

According to the American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education, the core competencies are knowledge, abilities, or the expertise that contribute to a physician’s overall ability to function at the highest level possible in order to meet the needs of his patients and the expectations of the medical profession.

Please select all that apply with respect to your proposal.* Interpersonal and communication skills
Medical knowledge
Patient Care
Practice-based learning and improvement
Professionalism
Systems-based practice

Osteopathic Medicine Relevance

As appropriate, the AAFP is interested in incorporating osteopathic medicine principles into education developed for both MDs and DOs. These principles emphasize the interrelated unity of all systems in the body, each working with the other to heal in times of illness.

Does your proposal include osteopathic medicine principles?* Yes
No

Presentation Format Description: (Please check one)

The baseline expectation is that you are able to effectively develop and deliver a didactic lecture. *Note: if you are submitting for a Clinical Procedural Workshop (CPW), the baseline expectation is that you teach a hands-on workshop. In addition to interactive lecture submission, the following educational formats are commonly used during LAFP CME meetings. You may select one or more of these additional formats. If your proposal is accepted, you will be notified as to acceptance of additional format proposal(s).

Didactic Presentation - 60 minutes (45-50 minute lecture; followed by 10-15 minute Q & A session).

Procedure Workshop - Minimum of 90 minutes of hands-on procedure or skill practicing.

Total length of proposed workshop:

Maximum audience size:

Panel Discussion

Two-hour Seminars - Maximum of 90 minutes of didactic presentation with a minimum of 30 minutes of interactive discussion, demonstration, and Q & A session. Speaker presents cases or clinical reviews of core curriculum for group discussion or asks attendees to bring cases with them for discussion.

Other:

If you marked other, plese provide details:

Do you have prior teaching experience?* Yes
No

Honorarium/Expenses

Please indicate the following:

Honorarium: Yes No

Expenses: Yes No

If you marked yes, what is the requested amount?

If you marked yes, please indicate what is requested: (please note that LAFP's Travel Policy will apply) Waived Registration Fee Travel Expenses

File Upload

Please upload the following files below:

Conflict of Interest Form

Bio: Document should contain 1,200 characters or less.

Professional Photo Headshot should be at least 400px wide by 600px tall in jpeg, tiff, or pdf format

Recording Acknowledgement

By singing this Faculty Agreement, I am consenting to this Affidavit and Audio/Videotaping Release. I affirm this proposal conforms to all of the LAFP’s submission instructions outlined. I understand that a presentation is a requirement of all LAFP Assembly CME programs. I agree to provide this presentation at least six weeks before the meeting. I understand that my failure to provide the presentation by the deadline could result in the cancellation of my presentation and could adversely affect the acceptance of future proposals. NOTE: Some programs are not audio/videotaped.

I acknowledge that my presentation may be recorded.*

Content Permission

In connection with my presentation at the LAFP CME Activity, I will prepare certain materials for distribution to program attendees. I give LAFP and its designee’s permission to use these materials as follows: Inclusion in compilations offered on electronic media, such as Online CME, CD-ROM or DVD. Inclusion as a part of LAFP program materials made available through the Internet and other online networks. Inclusion in reprints, anthologies and other LAFP publications.

Please list, by corresponding number, any of the above uses for which you are NOT granting permission:

Authors

My submission of this Faculty Agreement does not transfer my ownership rights in any materials and does not prohibit me from using my materials in any way I desire. This permission shall not expire and will not be affected even if I sell my copyright material.

I confirm that I am the sole author of the materials to be provided (except as noted below) and that LAFP’s use of these materials as described above will not infringe on the copyright of any other person or entity.

I further understand all speakers in this program must sign disclosure declarations and abide by the non-promotional guidelines set forth by the LAFP and the ACCME.

Other author(s) of these materials (if none, so state):*

Certification of Completion of COI

I have completed the CME Policy and Procedures for Full Disclosure and Identification and Resolution of Conflicts of Interest form.* Yes, I have completed the form
No, I have not completed the form

Additional Teaching Opportunities

Please indicate your interest in being considered for additional teaching opportunities.* I am interested.
I am not interested.

To prevent email Spam, please enter the letters and numbers you see to the right:

Thank you for submitting your faculty proposal for the 77th Annual Assembly and Exhibition. All proposals will be reviewed by the Education Committee and you will be notified if you have been selected to present during the meeting.

Please note that if you are selected as a presenter, the following items will be required:

Faculty Contract
Faculty Disclosure Statement
Speaker Requirement Form
Short Biography or Introduction
One copy of PowerPoint/handout
Digital head shot photograph
CV

If you have any questions, please contact the LAFP at 225.923.3313.

77th Annual Assembly & ExhibitionJuly 25 - 28, 2024Sandestin Golf & Beach ResortDestin, FL

Faculty CME Proposal Application

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77th Annual Assembly & Exhibition
July 25 - 28, 2024
Sandestin Golf & Beach Resort
Destin, FL