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Inclusive Excellence Symposium 2019
Sample Presentation Proposal


Start of Block: Presenter Information

  • ◯ Primary presenter __________________________________
  • ◯ Co-presenter 1 ____________________________________
  • ◯ Co-presenter 2 ____________________________________
  • ◯ Co-presenter 3 ____________________________________
  • ◯ Co-presenter 4 ____________________________________

If all of the presenters are undergraduate students, please provide the name and contact information of the faculty sponsor who can recommend the program.

  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________

The Primary Presenter is:

  • ◯ Faculty
  • ◯ Staff
  • ◯ Graduate student
  • ◯ Undergraduate student
  • ◯ Community member

Please answer the following about the primary presenter.

  • ◯ University/institution/organization ___________________________________________
  • ◯ Department ____________________________________________________________
  • ◯ Title___________________________________________________________________

Educational background (please answer items that apply to the primary presenter)

  • ◯ Highest degree and discipline _____________________________________
  • ◯ Current major _________________________________________________
  • ◯ Year in school (e.g., junior) _______________________________________

Please provide contact information for the primary presenter.

  • ◯ Preferred way to be addressed (e.g., Jennifer, Jenny, Dr. Garcia, etc.)
    ____________________________________
  • ◯ Email _____________________________________________________
  • ◯ Phone ____________________________________________________
  • ◯ Address ___________________________________________________

Please provide email addresses of co-presenters (leave this section blank if this is a single presenter proposal).

  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________
  • ___________________________________________________

End of Block: Presenter information


Start of Block: Presenter information

Please provide the following information about your proposed program


Title (100-character limit including spaces)

  • __________________________________________________________________________

Description of the program or abstract for a poster presentation (50-word limit; this will be used in the event program)

  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________

Please state why this topic is important for our community (250-word limit)

  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________

Session format (mark all that apply)

  • ◯ Didactic/lecture
  • ◯ Experiential
  • ◯ Role-play
  • ◯ Discussion
  • ◯ Panel
  • ◯ Poster

Program outline (the session lengths is 50 minutes). Please include a plan for participant engagement.

  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________

Please describe how your presentation will reflect this year's theme "disrupt" (250-word limit)

  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________

Please select subject areas that apply to the proposed program (mark top 3).

  • ◯ Race/ethnicity
  • ◯ Ability/disability
  • ◯ Gender identity/expression
  • ◯ Religion/spirituality
  • ◯ Indigenous status
  • ◯ Immigration
  • ◯ National origin/international students
  • ◯ Sexual orientation
  • ◯ SES/social Class
  • ◯ Age
  • ◯ Mental health
  • ◯ Medical Illness
  • ◯ Intersectionality
  • ◯ Communication
  • ◯ Self-awareness
  • ◯ Critical consciousness
  • ◯ Student engagement
  • ◯ Inclusive teaching
  • ◯ Social justice

Learning objectives (minimum 3)

  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________

Significant articles/references that are relevant to the program (minimum 3)

  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________
  • __________________________________________________________________________

What is your target audience? (mark all that apply)

  • ◯ Students
  • ◯ Faculty
  • ◯ Staff
  • ◯ Administrator
  • ◯ Community members
  • ◯ Under-represented members of the society
  • ◯ Majority-identified members of the society

Is this program appropriate for live broadcasting to USU Statewide Campuses?

  • ◯ Yes
  • ◯ No

Is this program appropriate for video-recording? Recordings may be posted on the USU website, shared on USU social media, or sent to the members of USU Statewide Campuses.

  • ◯ Yes
  • ◯ No

Is this program appropriate for a CE credit? If so, for which discipline/field?

  • ◯ Yes
  • ◯ Maybe
  • ◯ No

End of Block: Presenter information


Start of Block: Block 3

Please attach abbreviated CV or Resume of each presenter that highlights relevant expertise (2 page per presenter limit: You can only upload one document here, so please combine all of the CV/Resume in one file prior to uploading).

End of Block: Block 3


A printer-friendly version of this sample form can be accessed here.