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Trauma Update Biographical/COI form

Arkansas Trauma Update Biographical & Conflict of Interest Form

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  • Please list your administrative assistant's name and contact information (if applicable)

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  • Please upload a head shot for promotional purposes for the program.
  • Please upload your most current CV/resume
    *Off-label use is the practice of prescribing pharmaceuticals or devices for an unapproved indication or in an unapproved age group, unapproved dose or unapproved form of administration.
    Select all that apply.
  • If the target audience is not listed above, please list your target audience.
  • Please indicate any teaching methods you will be utilizing that are not listed above.


  • Please list the primary learning objectives for your presentation.

    Remember learning objectives must be consistent with the above activity type and must be measurable. If your target audience includes both pharmacists and technicians, you must write separate objectives for both audiences that apply to their scope of practice.

    (*Verbs to AVOID while writing objectives: appreciate, enjoy, really understand, be acquainted with, fully appreciate, realize, be aware of, grasp the significance of, remember, be familiar with, sympathize with, believe, know, understand, comprehend, learn)

  • Please list 2-3 learning objectives for your presentation.
  • This course will include a Self-Assessment Module for Part II Maintenance of Certification requirements. Please give three multiple-choice content questions that cover material you intend to discuss in your presentation. Be sure you indicate which answer is correct!
  • Please describe any special audio/visual or equipment needs for your presentation.