Multidisciplinary Symposium Submission Form
Thank you for your interest in submitting a project for Community Health Network’s and UIndy’s Annual
Multidisciplinary Scholarly Activity Symposium.
Submissions will be accepted
November 1, 2020 through February 1, 2021.
We welcome your participation and look forward to reviewing the many great scholarly activities being pursued by you and your colleagues. If you have any questions about submissions, please email Kaylee Burget at
All participants (entire project team) must return the electronic CME Disclosure Form before they can participate in the symposium.
Project Leads: Download the form and distribute to other project members. Project Team Members: Return the completed form to the project lead, who will combine all team members' forms into one document to be uploaded with this submission. Do not send individual forms for project members.
Save form with a unique file name that identifies the project lead or project title.
Download CME Disclosure Form How to Return the CME Disclosure Form
Project Leads: Attach form to this submission or email as an attachment to kburget2@eCommunity.com. Remember, this should contain the disclosure forms for ALL of your project team members. Project Team Members: Email your completed form to the project lead.
Additional People on Project
Include first and last name, credentials, email address and role for EACH person. Every field is required for each person added.
(Tip: Use the +/x controls to add or remove a person. Use the "Add Person" number selector to add multiple people at once.)
Please list 3 references.
For oral presentations, please list 3 learning objectives. This is required.
Pre- and Post- Questions
For oral presentations, please list pre- and post- presentation questions. This is required.