1. Format of Presentation: 

2. Public Health Disciplines: Choose the discipline that best fits your abstract.

3. PHIP Standards: (Choose one of the five that best fits your abstract.

4. Presentation Time Requested
--45 minutes  --90 minutes

5. Are you willing to adjust your time?  Yes No

6. Moderator: Do you have a moderator for your presentation? Yes  No  

    6A.  *If yes, is the moderator the primary contact person for this abstract?  Yes  No  

*Please note that all information regarding acceptance or decline of this abstract will go to the moderator if they are indicated as being the primary contact on the abstract.

    If you answer yes to #6, please provide the following information on the moderator; if not, proceed to #7.

Moderator First Name: 
  

Moderator Middle Initial/Name: (One letter and period only. Leave blank if you do not wish to enter one.)
 

Moderator Last Name:  
  

Moderator Degree(s):  (Abbreviations only, separate with a comma & space; do not use periods! Example: PhD, MPH)  
 

Moderator Position/Title:


Moderator Affiliation/agency: (Complete in full, i.e., Washington State Department of Health, or University of Washington)
 

Moderator Address 1 (Specific dept. within the affiliation/agency you work for, if none than enter street address or PO Box (not both)


Moderator Address 2 (Enter street address or PO Box (not both) if not already entered in Address 1; otherwise leave blank)


City:  State:  Zip:  (Include Zip+4, if known.)

(W) Phone:           E-mail: 

8. Abstract: 1,500 character limit (approx. 300 words.) The box below will wrap your text. 
   ***Please do not use the 'Enter" key unless you are starting a new paragraph***
 

9. Learner Objectives: You need to enter all three objectives of no more than 125 characters each. 
    Make each sentence a complete sentence. These are required for CEU approval.

   1. 
   2. 
   3.  

10. Audio/Visual Equipment: All A/V equipment will be provided, please choose from the list below.  To use laptops and LCD projectors provided by the Joint Conference A/V technician you will be required to submit your presentation to Richard Pedlar by October 1, 2007; otherwise you will need to bring your own LCD and laptop.  Slides will be converted to PowerPoint if provided by October 1st.  Screens will be provided in each room. Podiums and microphones will be provided based on the size of the room and room set-up.

11. Room Set-up: Select the room set-up that works best for your presentation:

Theater style - Rows of chairs, head table with podium for presenter(s). 

Class room style - Rows of chairs with 8 ft. tables, head table with podium for presenter(s).

Roundtable style - Round table seating 10 people each, no head table, wireless microphone provided if needed for presenter.

12. Media Coverage: Will you allow media coverage at your presentation? Yes No

13. Presenter (Primary): This is also the main contact person the JCH Coordinator.  If you answered "yes" to 6A above then the moderator will be the main contact for your presentation.

First Name: (If you use your middle name as primary name, please enter it here.)


Middle Initial/Name: (One letter and period only. Leave blank if you do not wish to enter one.)


Last Name:


Degree(s): (Abbreviations only, separating each with a comma and space; do not use periods! Example: PhD, MPH)


Position/Title:


Affiliation/agency: (Complete in full, i.e., Washington State Department of Health, or University of Washington)


Address 1 (Specific department within the affiliation/agency you work for, if none than enter street address or PO Box (not both)


Address 2 (Enter street address or PO Box (not both) if not already entered in Address 1; otherwise leave blank)


City:  State:  Zip:  (Include Zip+4, if known.)

E-mail:  (Please enter only one e-mail address.)

Presenter Bio: Limited to 800 characters (approximately 125 words.) The box below will automatically wrap your text. Enter in paragraph format.  

***Do not use the 'Enter" key unless you are starting a new paragraph.***

14. Panelist #1:
First Name: If you use your middle name as primary name, please enter it here.


Middle Initial/Name: One letter and period only. Leave blank if you do not wish to enter one.


Last Name:


Degree(s): (Abbreviations only, separating each with a comma and space; do not use periods! Example: PhD, MPH)


Position/Title:


Affiliation/agency: (Complete in full, i.e., Washington State Department of Health, or University of Washington)


Address 1 (Specific department within the affiliation/agency you work for, if none than enter street address or PO Box (not both)


Address 2 (Enter street address or PO Box (not both) if not already entered in Address 1; otherwise leave blank)


City: State: Zip: (Include Zip+4, if known.)

E-mail: (Please enter only one e-mail address.)

Panelist #1 Bio: Limited to 800 characters (approximately 125 words.) The box below will automatically wrap your text. Enter in paragraph format.  

 ***Do not use the 'Enter" key unless you are starting a new paragraph. ***

15. Panelist #2:
First Name: (If you use your middle name as primary name, please enter it here.)


Middle Initial/Name: (One letter and period only. Leave blank if you do not wish to enter one.)


Last Name:


Degree(s): (Abbreviations only, separating each with a comma and space; do not use periods! Example: PhD, MPH)


Position/Title:


Affiliation/agency: (Complete in full, i.e., Washington State Department of Health, or University of Washington)


Address 1 (Specific dept. within the affiliation/agency you work for, if none than enter street address or PO Box (not both)


Address 2 (Enter street address or PO Box (not both) if not already entered in Address 1; otherwise leave blank)


City: State: Zip: (Include Zip+4, if known.)

E-mail: (Please enter only one e-mail address.)

Panelist #2 Bio: Limited to 800 characters (approximately 125 words.) The box below will automatically wrap your text. Enter in paragraph format.  

***Do not use the 'Enter" key unless you are starting a new paragraph.***

16. Panelist #3:
First Name: (If you use your middle name as primary name, please enter it here.)


Middle Initial/Name: (One letter and period only. Leave blank if you do not wish to enter one.)


Last Name:


Degree(s): (Abbreviations only, separating each with a comma and space; do not use periods! Example: PhD, MPH)


Position/Title:


Affiliation/agency: (Complete in full, i.e., Washington State Department of Health, or University of Washington)


Address 1 (Specific dept. within the affiliation/agency you work for, if none than enter street address or PO Box (not both)



Address 2 (Enter street address or PO Box (not both) if not already entered in Address 1; otherwise leave blank)


City: State: Zip: (Include Zip+4, if known.)

E-mail: (Please enter only one e-mail address.)

Panelist #3 Bio: Limited to 800 characters (approximately 125 words.) The box below will automatically wrap your text. Enter in paragraph format.  Do not use the 'Enter" key unless you are starting a new paragraph.

17. Acknowledgements: If you have any other people you wish to acknowledge as part of your presentation that will not be a presenter, please indicate in this box their name(s) and credentials.  This information cannot be put in the abstract because of the anonymous review process; however, they will be acknowledged in the final program at the conference.

18. Comments: This field is for any information you need to provide to the JCH Coordinator that you were unable to provide in the fields above. If you are aware of any dates or times you will not be able to present at the conference or if you want to be paired with another presentation that was submitted please indicate that detailed information here.  Once abstracts are selected and scheduled into the conference we will not be able to move them. There is no guarantee we can accommodate your requests but we will make every effort to do so.