Primary Presenter/Applicant Information:

First Name:______________________Last Name:_______________Middle Name(or Initial):___

Degree:________OR Rank:_________________

Address Line 1:_________________________________________________________________

Address Line 2: ________________________________________________________________

City: ____________________State: _____________Zip/Postal Code: _____________________

Phone: _______________________________________________________________________

Email Address: _________________________________________________________________

Are you an FSPA member?

 Yes

 No

• •PRESENTER CV: Please attach a copy of the author’s curriculum vitae. Without thisdocument, the application will be considered incomplete and your application will notbe processed.

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Identification:

NAME/DEGREE/TITLE/AFFILIATION/ LOCATION

(Example: Sally Smith, Ph.D., Director, Private Practice, Los Angeles, CA OR Battalion Chief John Doe, Health and Safety Officer, Modesto Fire Department, Modesto CA) Please type in your information so it is similar to the above example. What you type in the box below will be listed in all of the conference promotional materials.

______________________________________________________________________________

Suggested Presentation Title:

Enter presentation title in the space below. 15 WORD MAXIMUM

This title may be edited by the Conference Committee for clarity and/or marketing.

TITLE:

Presentation Abstract:

Enter the abstract for your presentation in the space below, 50 WORD MAXIMUM. This description will be used in the Conference marketing materials and in the final program.

ABSTRACT ______________________________________________________________________________

Presentation Syllabus / Summary:

Type or paste your syllabus describing your presentation in the space below, 350 WORD MAXIMUM

Syllabus: ______________________________________________________________________________

Are you proposing a 20, 60 minute, or 90 minute presentation?

 20 minutes

 60 minutes

 90 minutes

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Presentation Learning Level:

 Beginner (No CE Eligibility for Mental Health Providers/ Intended Audience Fire Service Personnel)

 Intermediate

 Advanced

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What type of audience is your presentation geared for?

 Operations

 Consultation

 Assessment

 Intervention

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Presentation Learning Objectives:

Please provide three learning objectives for this presentation. If more than three are listed, the first three only will be used.

LEARNING OBJECTIVE EXAMPLES: Identify challenges to healthy intimate partner relationships including unpredictability of the nature of work. Explain the role of shift work on relationship dynamics

In writing your three learning objectives please use measurable terms such as: identify, describe, explain, discuss, and evaluate.

1.After attending this presentation participants will be able to:________________________________________________________________________________________________________________________________________________

2.After attending this presentation participants will be able to:________________________________________________________________________________________________________________________________________________

3.After attending this presentation participants will be able to:________________________________________________________________________________________________________________________________________________

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Method of Teaching:

1.How will the presenter encourage discussion and interaction in your session.

______________________________________________________________________________

2.What will be the take-home points that can be immediately used in practice?

______________________________________________________________________________

Participants:

I will be the only presenter for this workshop.

 Yes

 Νο

If you are proposing a panel, are you including a member from a profession other than psychology or the fire service (example: politician or medical doctor)?

 Yes

 No

Additional Presenters (if applicable):

All information is required.

PRESENTER 2:

First Name:______________________Last Name:_______________Middle Name(or Initial):___

Degree:________OR Rank:____________

Address Line 1:_________________________________________________________________

Address Line 2: ________________________________________________________________

City: ____________________State: _____________Zip/Postal Code: _____________________

Phone: _______________________________________________________________________

Email Address: _________________________________________________________________

Are they an FSPA member?

 Yes

 No

• •CV Requirement: Please attach a copy of the presenter’s curriculum vitae. Without thisdocument, the application will be considered incomplete and your application will notbe processed.

PRESENTER 3:

First Name:______________________Last Name:_______________Middle Name(or Initial):___

Degree:________OR Rank:______________

Address Line 1:_________________________________________________________________

Address Line 2: ________________________________________________________________

City: ____________________State: _____________Zip/Postal Code: _____________________

Phone: _______________________________________________________________________

Email Address: _________________________________________________________________

Are they an FSPA member?

 Yes

 No

• CV Requirement: Please attach a copy of the presenter’s curriculum vitae. Without thisdocument, the application will be considered incomplete and your application will notbe processed.

PRESENTER 4:

First Name:______________________Last Name:_______________Middle Name(or Initial):___

Degree:________OR Rank:______________

Address Line 1:_________________________________________________________________

Address Line 2: ________________________________________________________________

City: ____________________State: _____________Zip/Postal Code: _____________________

Phone: _______________________________________________________________________

Email Address: _________________________________________________________________

Are they an FSPA member?

 Yes

 No

• •PRESENTER CV: Please attach a copy of the presenter’s curriculum vitae. Without thisdocument, the application will be considered incomplete and your application will notbe processed.

Will your presentation require any other type of equipment in the presentation? (For example, fire apparatus, arson-crime scene investigation material, etc.)

Authorization – By submitting this proposal I agree to the following:

 All of the information is true and complete. This application is a accurate representation of the information I am proposing to present at the FSPA conference.

 I understand and agree to all of the instructions and rules.

 I understand that, if my proposal is accepted, all presenters in my session will be required to register for the conference and will receive a reduced registration rate.

 I give permission to FSPA to use all or part of my presentation for publicity purposes.

 I agree that all presenters in my session will appear and deliver the presentation, if accepted.

 I give permission to FSPA to edit my presentation title and/or abstract as necessary for publication purposes.

 Unless otherwise agreed upon, I understand that I will not be paid to present my workshop(s) and I will not be reimbursed for any expenses.

 I agree to provide electronic files of my handouts to FSPA by the deadline in the presenter contract.

I understand that if my proposal is incomplete it will not be reviewed by the program committee.

 I understand that I will be responsible to provide a laptop if I wish to use PowerPoint during my presentation.

NOTE: Primary presenter is responsible for notifying co-presenters of ALL presentation details. I agree with the above. NAME:_______________________________________________DATE:____________________ SIGNATURE:____________________________________________________________________

Important Dates / Deadlines

August 31, 2022 – Proposal Deadline

September 5, 2022 – Notification of presentation acceptance or rejection sent via email to the primary presenter.