Call for 2022 PhyzTalks Application

1. Contact Information

First Name *This question is required.

Last Name *This question is required.

Credentials *This question is required.

Company Name/Institution *This question is required.

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address *This question is required. This question requires a valid email address.

Office Number *This question is required. This question requires a valid number format.

Mobile Number *This question is required. This question requires a valid number format.

Years Out of Practice or Resident/Fellow? (Note: medical students do not qualify for PhyzTalks). *This question is required.

2. Your biography. Please provide a brief summary of your education, work history, and experience, not to exceed 200 words. *This question is required.

3. Title of your PhyzTalk story. This title will be listed in all promotional materials and programs. *This question is required.

4. Your PhyzTalk story. Include a detailed description or summary of the story you’d like to present, not to exceed 500 words. *This question is required.

5. Have you presented before? Please provide a list or summary of your past presentation experience, including whether you have presented on this topic. (Note: past presentation experience is not required).

6. How do you think your story could impact physiatrists or the physiatrist community? What is your take-home message? *This question is required.

7. At this time, do you anticipate being able to travel to Baltimore for the in-person Annual Assembly?
All faculty are expected to be in-person for the 2022 Annual Assembly in Baltimore. This session will be held virtually, being live-streamed out to virtual participants. *This question is required.

8. Are there any special considerations the reviewers should be aware of? Would your presentation have any special audiovisual, or other technical/logistical support needs? (Include N/A, if none)

9. Any other comments on why you should be selected?