CAMC Institute for Academic Medicine Podcast Application

CAMC INSTITUTE FOR ACADEMIC MEDICINE PODCAST

PODCAST TITLE, DESCRIPTION AND OBJECTIVES

Please type or print clearly

Host

Organization / Credentials

Title of Session

Guests (up to 2 maximum) - Remote* or In CAMC Studio

*If guest is participating remotely, please ensure guest is using studio or soundbooth to ensure quality and integrity of audio recordings.

Brief description of session

Objective 1: By the end of this session, participants will be able to

Objective 2: By the end of this session, participants will be able to

Objective 3: By the end of this session, participants will be able to

PODCAST GUEST: Biographical Data Form

Note: Please complete this form for each speaker and/or panelist

Speaker's Name

Credentials

Address

Phone

Fax

Cell Phone

E-mail

Education (including basic preparation through highest degree held):

Degree 1

Year 1

Institution 1

Institution City and State 1

Degree 2

Year 2

Institution 2

Institution City and State 2

Degree 3

Year 3

Institution 3

Institution City and State 3

The following information will appear in the podcast and other materials, and be used for introductions.

Current Position

Provide a one paragraph description of your professional experience or areas of expertise (including publications) related to the topic of your presentation

True / False Questions for Post Test (for archived podcast / enduring material)

Question 1

Question 2

Question 3

Question 4

Question 5