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

This form supplements the main CERT Approval form
Name of Program/Symposium*
Lecture Title*
Name of individual filling out this form*
First Last
Email*
Date*
Date Format: MM slash DD slash YYYY
Start Time*

: HH

MM
End Time*

: HH

MM
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.
Name
This field is for validation purposes and should be left unchanged.

CERT “Form A” – form