CERT “Form A” – form This form supplements the main CERT Approval formName of Program/Symposium*Lecture Title*Name of individual filling out this form* First Last Email*Date* Date Format: MM slash DD slash YYYY Start Time* : HH MM AM PM End Time* : HH MM AM PM Length*Are other lectures being held during this same time?*YesNoSpeaker Information*Include credentials as they relate to the expertise on the topic to be presented. Do not submit CV.Learner objectives*What do you expect the participant to be able to learn or do after the lecture? Evaluation methods*Describe the methods use to measure if the objectives were met. Example, pre or post test, questionnaires, skill checkoff, etc.PhoneThis field is for validation purposes and should be left unchanged.