Course Planning Form – Therapy Insights

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Email*

You will receive a confirmation of this form delivered to this address.

Your full name with credentials as you would like it to appear on marketing and course materials*

Your bio (700 character limit)*

Upload a headshot we can use for marketing purposes.*

Max. file size: 50 MB.

List any social media handles where we can tag you. (E.g., Instagram: @therapyinsights)

Cell phone number*

This will only be used in the case of significant technical issues on the day of presentation, such as you getting disconnected and not knowing it.

Would you prefer to be paid via paper check or PayPal?*

Paper check

PayPal

All payments are sent on the 1st of the month following live presentations. For example, if you present March 12, you would be paid April 1. PayPal payments are sent on the 1st. Paper checks are sent on/around the first and arrival date depends on USPS schedule.

What is the email address associated with your PayPal account?*

Mailing address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Course title (80 character limit)*

Learning objectives (PT courses: Minimum of 5. SLP and OT courses: Minimum of 3.)*

Course description (400 character limit). Tip: include your learning objectives.*

Proposed time-ordered agenda. Please break down the course in 10, 15, or 20 minute chunks and provide a broad overview of what you will cover in each section. Be as specific as possible.*

Example of a time-ordered agenda:
0:00 - Overview of head and neck anatomy
0:10 - Treatment options for head and neck cancer and their impact on anatomy/physiology of the neck
0:20 - Recent research studies looking at the effect of proactive dysphagia treatment in head and neck cancer
0:30 - 2 case studies of patients with head/neck cancer with proactive or reactive dysphagia treatments
0:45 - Recommended treatment protocols
0:55 - Q/A 1:00 - End course + quiz

Instructional level*

Introductory (Information is geared to practitioners with little or no knowledge of the subject matter. Focus is on providing general introductory information.)

Intermediate (Information is geared to practitioners with a general working knowledge of current practice trends and literature related to the subject matter. Focus is on increasing understanding and competent application of the subject matter.)

Advanced (Information is geared to practitioners with a comprehensive understanding of the subject matter based on current theories and standards of practice as well as current literature and research. Focus is on recent advances and trends, and/or research.)

Will you be mentioning any products or services that you sell? (It's ok if you do- we will work with you to make sure we present it in a way that is not a conflict of interest.)*

Yes

Briefly describe the products you'll be mentioning.*

Any course pre-requisites required?*

Yes

Please describe the required pre-requisites.

We require that presenters offer one of the following:

Share a copy of your slide deck.
Create a Guided Notes document for learners.

Guided notes are instructor-prepared handouts that provide all students with background information and standard cues with specific spaces to write key facts, concepts, and/or relationships during the lecture. If you select this option, we will professionally design your Guided Notes for you. You will need to provide a rough outline (either a sketch or a text document).

Please select one:*

I will share a copy of my slide deck

I will create a guided notes document

Please paste in your list of course references. Please list in alphabetical order in APA format. MAX 15 RESOURCES. Please prioritize your most relevant references. None older than 15 years. If you feel that a source is valid and older than 15 years, please provide a rationale.*

If you have more than 15 references you need to include, please make a note here and be sure to include all references in your slide deck.

To comply with the Health Insurance Portability and Accountability Act (HIPAA), we ask that all course planners and instructional personnel insure the privacy of their patients/clients by refraining from using names, photographs, or other patient/client identifiers in course materials without the patient’s/client’s knowledge and written authorization.*

I am in compliance with these policies.

Do you have any personal disclosures? For example, you have a personal friendship with someone in the company whose products are discussed in the course; you have a family member or friend with a disorder that will be talked about in the course.*

Yes

Please list your personal disclosures.*

Do you have any professional disclosures? For example, you are a member of an association or group that is talked about or referenced in the course; you have a professional bias about a way to deliver a particular service.*

Yes

Please list your professional disclosures.*

Do you have any political disclosures? For example, you have a political bias about a topic (e.g., health care reform) and your bias is toward supporting a particular party's position on this issue.*

Yes

Please list your political disclosures.*

Do you have any institutional disclosures? For example, you have a political bias about a topic (e.g., health care reform) and your bias is toward supporting a particular party's position on this issue. member of that organization or give money to its causes.*

Yes

Please list your institutional disclosures.*

Do you have any religious disclosures? For example, you have a bias based on religious tenets (e.g., a bias toward service delivery at end of life based on religious beliefs).*

Yes

Please list your religious disclosures.*

Do you have any bias disclosures? For example, you have a bias based on personal life experience that may influence the content of the course.*

Yes

Please list your religious disclosures.*

Do you receive a salary?*

Yes

Please list the company or institution that pays you a salary.*

Do you receive consulting fees from any company or organization related to the topic of this course? For example, do you provide consulting services (outside the scope of employment) that bring in revenue for you that is specifically related to the course content?*

Yes

Please briefly describe the nature of your consulting work related to the topic of this course.*

Do you currently hold any intellectual property rights (e.g., copyright, patents, trademarks) on any of the content being presented in this course?*

Yes

Please briefly describe the nature of your intellectual property as related to the topic of this course.*

Do you currently obtain any speaking fees (separately from what Therapy Insights provides) related to the topic of this course? For example, do you receive any speaking fees from publishers or product distributors any time you speak on this topic?*

Yes

Please briefly describe the nature of your speaking fees as related to the topic of this course.*

Do you currently receive any grant funding related to the topic of this course? For example, a grant from NIH, NSF, philanthropists, etc.*

Yes

Please briefly describe the nature of your grant funding as related to the topic of this course.*

Do you currently receive any gifts related to the topic of this course? For example, an individual, company, or organization provides gifts of any kind in exchange for your time and dedication to this topic. (Other than Therapy Insights)*

Yes

Please briefly describe the nature of the gifts you receive as related to the topic of this course.*

This course will serve...*

PTs (adult-based)

OTs (adult-based)

SLPs (adult-based)

SLPs (pediatric-based)

The following resource may be useful when addressing AOTA's questions below:
Section 11 | Relevance to Occupational Therapy

Which AOTA-defined category most aligns with this course?*

OT Service Delivery: Evaluation, intervention, or outcomes.

OT Professional Issues: Admin, legal, education programs, or research.

OT Foundational Knowledge: Medical information, background, or context relevant to OT practice.rd Choice

Select which sub-category most aligns with this course:*

Evaluation: Provides an understanding of the client’s occupational history and experiences and analysis of occupational performance.

Intervention: The use of occupations and activities, preparatory methods and tasks, education and training, advocacy, and group interventions to facilitate engage

Outcomes: Determinants of success in reaching the desired end result of the occupational therapy process. Outcome assessment information i

Select which sub-category most aligns with this course:*

Administration & Management: Planning, organizing, controlling, and directing the activities organization to achieve desired outcomes in occupation- centered practice.

Legal, Legislative, Regulatory & Reimbursement Issues: Coding and reimbursement, documentation, licensure and scope issues related to occupational therapy practice.

OT Education: Development, delivery, or administration of occupational therapy education and continuing professional development, including experiential components of occupational therapy education programs.

OT Research: Clinical and academic activities that support scientific procedures and processes to gather data and generate knowledge that enhance the profession and clinical practice of occupational therapy.

Supervision: Ensuring the safe and effective delivery of occupational therapy services and fostering professional competence and development. Contemporary Issues and Trends: Potential role of occupation in addressing societal issues

Select which sub-category most aligns with this course:*

Human Body, Development, and Behavior: Diagnoses & conditions, biological and physical sciences, neurosciences, kinesiology, biomechanics, human development, behavior

Sociocultural, Socioeconomic, Diversity Factors, and Lifestyle

Choices: Understand the impact of sociocultural, socioeconomic, and diversity factors, as well as lifestyle choices in contemporary society to meet the occupational needs of persons, groups, and populations.

Social Determinants of Health: Determinants of health for persons, groups, and populations with or at risk for disabilities and chronic health conditions.

OT History, Philosophical Base, Theory, and Sociopolitical Climate: Occupational therapy history, philosophical base, theory, and sociopolitical climate and their importance in meeting society’s current and future occupational needs.

Describe how the proposed PD activity addresses occupation-based assessment, intervention, and or outcomes.*

Demonstrate how the proposed PD activity meets the requirements of Professional Issue that pertains to the practice of occupational therapy.*

Identify teaching strategies (e.g., case studies, Q&A) that the proposed PD activity will use to explicitly link the Professional Issues to OT Practice and/or education.*

Demonstrate how the proposed PD activity meets the requirements of Foundational Knowledge that pertains to the practice of occupational therapy.*

Identify teaching strategies (e.g., case studies, Q&A) that the proposed PD activity will use to explicitly link Foundational Knowledge to OT practice and/or education.*

Does the activity focus on interventions to support occupation (formerly preparatory methods)? Preparatory methods are used in preparation for purposeful and occupation-based activities. Examples include sensory input to promote optimal response, modalities (ultrasound, electrical stimulation, etc), splinting, and exercise.*

Yes

Demonstrate an explicit connection between the interventions to support occupations (formally preparatory methods) and occupation-proximal (immediate) practice, which includes client ability to participate in desired occupations in context. This is AOTA's question, not ours. They are looking for language that ensures that the course is related to OT.*

Provide a statement on the strength (e.g., levels of evidence) of the information of your sources and provide a rationale for how the evidence meets industry acceptable standards, reflects best practice, is up to date and supports the PD activity. Please provide a rationale for references that are greater than 15 years old. (Also AOTA's requirement). This link may be useful: https://otpotential.com/blog/levels-of-evidence-in-ot*

Please upload a text document (Word, Pages, or TextEdit formats are fine) containing 4 quiz questions that are true/false or multiple choice. Please bold the correct answers. Questions should be straightforward and easy to answer for anyone who attended the course.

Max. file size: 50 MB.

I attest that the information in this disclosure is accurate at the time of completion and I agree to notify The Therapy Insights Continuing Education Task Force of any changes to this information between now and the presentation. By typing my name, I am signing this document.*

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