*First Name: *Last Name: *List Degrees above Bachelors: *Title: *Organization/Agency: City: State: * Zip Code: *Phone: Cellphone:

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1 The following information is to be completed by the individual coordinating this proposal. Unless you tell Information Insights staff otherwise, you will become the point of contact and we will assume you will communicate with others involved in your proposal. A mailing address for each participant is needed for the distribution of printed materials. Note questions with * require a mandatory entry before you may continue on with the form. *1. Contact Information: Much of this question is mandatory as it will be used for contact information and the program as this process moves forward. You may use abbreviations.(*required) *First Name: *Last Name: *List Degrees above Bachelors: *Title: *Organization/Agency: City: State: * Zip Code: *Phone: Cellphone: *2. Describe your role(*required) Select one. I will be presenting I will be coordinating a panel, including serving as a presenter, and will be responsible for communicating information to the panel I will be coordinating a panel and will serve as the point of contact but am not presenting. I will, however, coordinate communication of information to the panel Explain if the above choices don't work for you:

2 3. What are you proposing to do: Select all that apply. Breakout Session 60 minutes Breakout Session 75 minutes Breakout Session 90 minutes (generally a panel of speakers) Poster Session to present data during a designated time; might include handouts Round Table discussion: In a roundtable session each presenter is assigned to a specific table where attendees will have the opportunity to have an in depth discussion with presenters Post-Summit Session typically a half or full day intensive skill building, planning and/or coalition development opportunity Pre-session Sunday or Monday before, typically a half or full day Host a Coalition Meeting before or after a day's sessions Other, please explain:: 4. Please let us know how many individuals will participate in your presentation. Panels cannot be larger than 4 but may include a 5th individual to serve as the moderator. You will have a chance later to provide specifics on the additional panel member(s). Select one. 1, just myself includes the moderator

3 Which track does your proposal session fit in best? Please answer in #5, below. Policy and Systems Change Public policies and the structures of public health and health care systems have a profound impact on the health of populations. This track will highlight the importance of policy and systems change for improving population health and health care. Social and Economic Determinants of Health track aims to discuss social, education, health, economic, physical, and environmental determinants of health. It also seeks to identify methods to achieve health equity and improve the health status for individuals, communities, and regions as a whole. Public Health Core Competencies and Workforce Development track provides information, discussion and networking opportunities for public health professionals to learn about current trends in public health concepts and practice to address public health problems in Alaska. Public Health Research and Evaluation track highlights programs and projects that demonstrate contributions to the scientific foundation for improving health through public health science, research, evaluation and translation to practice. Alcohol/Substance Abuse track will focus on issues specific to our circumpolar environment and showcase emerging and promising practices in promotion, prevention, treatment and recovery, both behavioral health and public health approaches, to reduce the number of Alaskans who experience alcohol and other drug dependence and abuse. 5. Which track does your session fit in best? See descriptions, above: Select one. Policy and Systems Change Social and Economic Determinants of Health Public Health Core Competencies and Workforce Development Public Health Research and Evaluation Alcohol and Substance Abuse

4 6. The following may assist you in focusing your session description and its intended audience. Please mark yes or no if the presentation will address any of the following categories. You may select more than one. Select one per row. Monitor health status to identify community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health effort. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems. Assure a competent public health and personal health care workforce. Yes No

5 7. Audience: Participants work with many segments of Alaska's population. Please indicate below which populations your presentation covers. Select one per row. Infants and children Adolescents Young adults Young parents Women Elders Local government and policy makers Community coalitions Other health providers Children Adults Employees Families Men General Public Health Professionals Low Income Low Literacy Older Adults Parents Patients Schools/Students Persons with disabilities Yes No

6 *8. Session title: This title may be a work in progress but should give the planning committee an idea about your topic.(*required) *9. Description of session, not to exceed 150 words. NOTE: Longer descriptions will be truncated at the word limit. Include information about what the presentation will cover, who might attend, and how it relates to the Summit theme: Healthy Alaskans, Every Day, Every Community(*Required)

7 10. Tell us about the presenter(s). There are multiple spaces for up to 4 panelists and a space for a moderator. Panels are not a requirement, however information is needed on every presenter whether presenting alone or in a panel. Presenter (or first panelist if you have a panel) First Name: Last Name: Title: List Degrees above Bachelors: Organization/Agency: If you have a panel, tell us about your 2nd panelist. Otherwise you may skip ahead to Continuing Education and Learning Objectives. First Name: Last Name: List Degrees above a Bachelors: Title: Organization/Agency: If you have a panel with 3 people, tell us about your 3rd panelist. Otherwise you may skip ahead to Continuing Education and Learning Objectives. First Name: Last Name: List Degrees above a Bachelors: Title: Organization/Agency:

8 13. If you have a panel with 4 people, tell us about your 4th panelist. Otherwise you may skip ahead to Continuing Education and Learning Objectives. First Name: Last Name: List Degrees above a Bachelors: Title: Organization/Agency: You have reached the maximum number of participants you may have in a panel. You may add one more participate who will serve the role of Moderator. If you do not have a moderator, you may skip ahead to Continuing Education and Learning Objectives. The Moderator will be: First Name: Last Name: List Degrees above a Bachelors: Title: Organization/Agency:

9 Continuing Education Information: For your session to qualify for contact hours for nurses, you must provide one (1) learning objective per hour of teaching. They must be written to reflect what attendees will be able to do differently after participating in the session. Objectives should be in behavioral terms such as "discuss, describe, list, identify, analyze, synthesize." Objectives submitted as "understand or know" will be modified. This activity has been submitted to Montana Nurses Association for approval to award contact hours. Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. *15. Learning Objective 1:(*Required) 16. Learning Objective 2 (optional for longer presentations)

10 17. Learning Objective 3 (optional for longer presentations) 18. Learning Objective 4 (optional for longer presentations)

11 19. If you are proposing a presentation, please indicate how long you believe the session should be. Select one. 60 minutes 75 minutes 90 minutes Poster Roundtable Plenary/Keynote Other: please explain: 20. Resources: If you are selected as a speaker, you qualify for a speaker discount on the registration fee. Because ALPHA has limited resources, will you have resources to cover the balance of your registration costs? Select one. Yes No

12 Special or extended topic opportunities. PRE-SUMMIT INTEREST: To be held Sunday, January 25 or Monday, January 26 POST-SUMMIT INTEREST: To be held Friday, January 30. There is limited space for pre- and post-summit sessions. Reserve on a first come, first serve basis. Session spaces will be coordinated through Information Insights. Session host or organizer will coordinate food services directly with the hotel after Information Insights confirms space with the appropriate hotel staff. Post Summit advertising/publication in program and on the web cost is $75. Reserve by September 15. Registration is handled by the organization unless you choose to contract with Information Insights for assistance. In the space following, provide the following information: Topic/Session Title and length of time needed for session expressed in hours or days Your target audience Estimated number of attendees Contact, including phone, address, Catering needs anticipated (not a commitment at this point) Will you want assistance from Information Insights beyond the $75 advertising in the program, health summit promotion and website? Other relevant information 21. NEW OPTION: Pre-Summit Interest: If you have interest in reserving a pre-summit space on January 25 and/or 26, 2015, please address the points above, in the space below

13 22. Post-Summit Interest: If you have an interest in reserving post summit space, please address the points above, in the space below.