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Technology Conference Abstract Submittal

Technology Conference

Title:*

Purpose:*

Objectives:*

Limit to one or two

Overview of Presentation:*

Equipment needed:
LCD Projector
Computer
Online Access
Other

If you selected Other above, please describe:

Submitted for:*
Presentation
Poster

Check all that apply

If not accepted for a presentation would you do a poster?:*
Click to choose Yes No

Acknowledge potential conflict of interest:*
Click to choose Yes No

If yes, please describe the nature of the conflict:

Type of Audience Intended:
Academic Administrators
Advanced Practice Nurses
Allied Health Care Provider
Clergy/Chaplains
Counselors
Educators
Funeral Directors
Hospital Administrators
Informatics
Physician Assistants
Physicians
Social Workers
Staff development
Staff Nurses
Other

If Other is selected, please specify:

Principal Presenter's Name and Credentials:*

Email:*

Employer:*

Home Address:*

Employer Address:*

Position/Title:*

Phone - Work:*

Phone - Home:*

Phone - Cell:

Daytime Phone:*
Work
Home
Cell

Professional Experience:*

Education:*

Include: Institution(s), Degree(s), and Date of Degree(s)

Co-presenters:

Pleast provide names(s), credentials, address(s), work and home phone, email and affiliations for all co-presenters

Abstract:*

You can copy and paste your abstract here.

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Rutgers, The State University of New Jersey
All rights reserved.