CERT “Form A” – form – Texas Society for Respiratory Care.

Complete this form for EACH speaker.
**Complete this form for each speaker and presentation offered for this program. ** Forms will not be reviewed for approval until the application and payment is received.
Name 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 Name and Email*
Include the speaker’s first and last name along with the email address.
Speaker Information*
Include credentials as they relate to the expertise on the topic to be presented. Do not submit CV.
Learner objectives*
Learner objectives: minimum of 2 [reference Bloom’s Taxonomy Measurable Verbs] [What do you expect participants 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.
This form supplements the main CERT Approval form
**Complete this form for each speaker and presentation offered for this program. ** Forms will not be reviewed for approval until the application and payment is received.
Phone
This field is for validation purposes and should be left unchanged.

Complete this form for EACH speaker.