| Contact Information |
| Prefix: * |
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| First Name: * |
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| Middle Initial: |
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| Last Name: * |
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| Credentials (ACA, BC-HIS, etc.): |
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| Job Title: * |
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| Company: * |
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| Street Address: * |
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| Street Address (2): |
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| Mail Stop/P.O. Box: |
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| City: * |
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| State/Province: * |
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| Zip/Postal Code: * |
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| Country: * |
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| Phone: * |
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| Fax: |
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| Cell: |
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| E-mail: * |
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| Company Website: |
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| Brief Biography: * Please provide a 3-5 sentence professional biography of the instructor(s) (200 word limit). |
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| Presentation Information |
| Presentation Title: * |
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| *Abstract: * Please provide an abstract (limit 300 words) describing your presentation. |
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Presentation Bullet Points: * (learning objectives, knowledge outcomes, key ideas) Please provide 3 brief bullet points describing what attendees will learn from your presentation. If selected to present, these may be used in marketing materials. |
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Who is the target audience for this topic? * |
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Why is this topic important to this audience? * Please provide any history, trends, examples that make this presentation vital to current hearing aid specialists. |
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Level: *
Beginner
Advanced
Other
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Topic Area: * (Check all that apply) Refer to the IHS approved categories of instruction. |
Hearing Science
Audiometric Assessment
Audiometric Interpretation
Patient Selection Criteria
Hearing Instrument Technologies
Selecting Amplification Technology
Instrument Fitting Techniques
Counseling
Practice/Business Management
Sanitation Protocols
Ear Impressions
Validation/Verification
Professional Communication
Non-Amplification Hearing Systems
Federal Regulation
Other
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Presentation Format: * (Check all that apply) |
Lecture
Hands-on
Panel Discussion
Other
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| Commitment |
| If you have any supporting documents to accompany this application, please email the documentation directly to education@ihsinfo.org. |
| *I agree to provide an outline of my presentation by August 1, 2012. (Please respond yes or no) |
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Yes
No
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| *I agree to provide completed presentation slides by August 31, 2012. |
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Yes
No
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| *I agree that I have obtained the necessary permission to present the information described in this abstract. (Please respond yes or no) |
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Yes
No
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| *I agree to provide a substitute speaker in the unlikely event I need to cancel my participation. (Please respond yes or no) |
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Yes
No
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| *I agree to provide an article on this topic for The Hearing Professional magazine. (Please respond yes or no) |
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Yes
No
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