The 26th Forum for Behavioral Science in Family Medicine
Doubletree Guest Suites Chicago-Downtown
(NEW CONFERENCE LOCATION - SAME GREAT CITY)

Presentation Proposal

PRESENTER INFORMATION: (type or print as you wish to appear on a participant list). List additional presenters on a separate sheet including presenter information below.

ALL PRESENTERS MUST REGISTER

Name & Degree(s): _________________________________________________
Title/Program: _____________________________________________________
Address: _________________________________________________________
________________________________________________________________
________________________________________________________________
Phone/Fax/E-mail _______________ ________________ __________________

Name & Degree(s): ________________________________________________
Title/Program: ____________________________________________________
Address: ________________________________________________________
_______________________________________________________________
_______________________________________________________________
Phone/Fax/E-mail _______________ ________________ _________________

Name & Degree(s): ________________________________________________
Title/Program: ____________________________________________________
Address: ________________________________________________________
_______________________________________________________________
_______________________________________________________________
Phone/Fax/E-mail _______________ ________________ _________________

PRESENTATION TITLE (maximum of 70 characters)
________________________________________________________________

PRESENTER NAME(S) (please type or print as you wish to appear on program brochure)
____________________________________ ____________________________
____________________________________ ____________________________
____________________________________ ____________________________

SUBMISSIONS MUST BE RECEIVED BY March 21, 2005 IN ORDER TO BE CONSIDERED

ABSTRACT

Prepare your abstract in a typed, finished format using the specification below. (We reserve the right to edit). Upon final acceptance, seminar/workshop abstracts will be printed and mailed with the final program. Faxed forms will not be accepted. Do not include presenter identification on this page.

1. Describe the problem or gap your presentation addresses
2. List goals and objectives of your presentation
3. Include teaching methods and use of time to meet objectives
4. Avoid or define new conceptual terms
5. Limit abstract body to 200 words
   

PRESENTATION TYPE:
Workshop: 2 hours _______
Seminar: 1 ½ hours ________
Networking Breakfast: 1 hour _______

EQUIPMENT NEEDS:
*LCD projector ___________
VHS/VCR _______________
Overhead Projector _________
35 mm Slide Projector ________

*Please note: If you have marked off an LCD projector, you will have to supply your own laptop.

NUMBER OF PRESENTERS: __________

Mail 5 copies to:

Mary Ellen Radjenovich
Medical College of Wisconsin
Department of Family & Community Medicine
8701 Watertown Plank Road
Milwaukee, WI 53226-0509

Or Email to: meradjen@mcw.edu