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* MM slash DD slash YYYY Start Time* : Hours Minutes AM PM End Time* : Hours Minutes AM PM Length* Are other lectures being held during this same time?* Yes No Speaker 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. NameThis field is for validation purposes and should be left unchanged.