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This form was designed to be printed using your browser menu print command.   Mail or fax the completed form to the address listed on page 1.  The location of this page is: http://www.michiganspeechhearing.org/call4papersform3.html

2009 MSHA Annual Conference
March 26-28, 2009
Ritz-Carlton Hotel, Dearborn,  Michigan

ASHA CEU and (State Board) SB-CEU Information Form


Name(s) and credentials of presenter(s): ______________________________________________________

_____________________________________________________________________________________________

Address (with City, State, and Zip): _____________________________________________________________

______________________________________________________________________________________________

Work Phone: ( _____ )_________________         

Employer:_____________________________________________________                                                                                                          

City & State____________________________________________________

Expertise or Skills (limit to one area): ____________________________________________________________

Title of Presentation: ___________________________________________________________________________

Session Type:

/  /  Short Course (3 hours)                                             
/  /  Double Mini-Seminar (2 hours)    
/  /  60 Minute Mini-Seminar (1 hour) 
/  /  Poster Session (1 hour)
/  /  Grand Rounds or Panel Discussion (1 hour)

Instructional Level: (circle)                 Introductory            Intermediate             Advanced

Intended Audience: (e.g., those who work with adults, or young children, or adolescents,  etc.):  

Learning Outcomes:

 

Assessment of Learning Outcomes:

 

Activities: (e.g., lecture with discussion, etc.):

 

Materials: (slides, handouts, etc.): 

Note:  If you would like us to acknowledge your contribution as a presenter to MSHA - to your employer - please provide us with your supervisor's name and address: