PROPOSAL COVER SHEET

Fill in all information requested below. A 600-800 word summary must be attached to this proposal cover sheet.

1.	Type of Presentation: ___ Interactive Poster Only ___ Interactive Poster or Paper ___ Paper Only Symposium ___Chair ___Presenter Workshop ___ 3 Hour ___ 6 hour
2.	Title of Presentation (10 words maximum):
	IF YOU ARE CHAIRING A SYMPOSIUM OR LEADING A WORKSHOP: Title of Symposium or Workshop:
	SELECT FROM CONFERENCE TOPIC LIST:
3.	First Topic Choice: blank space 2-DIGIT NUMBER TOPIC Second Topic Choice: blank space 2-DIGIT NUMBER TOPIC
4.	___Principal (presenting/corresponding) Author or ___Participant in a symposium or workshop blank space ___Order of presentation (1st, 2nd, 3rd, etc.)     FIRST NAME   INITIAL   LAST NAME Highest Educational Degree: Complete Mailing Address:         STREET         CITY   STATE ZIP       PROVINCE   COUNTRY   Telephone: Work: (      ) Home: (      ) E-Mail: Fax: Affiliation:     DEPT. AND SCHOOL / AGENCY OR ORGANIZATION         CITY   STATE ZIP Photocopy this form to provide complete information (name, address, etc.) For each coauthor.
5.	Type of audiovisual equipment needed: ___ 35mm Slide Projector ___Overhead Projector ___VCR
6.	Please check the professional discipline of the principal author: ___EAP Specialist ___Epidemiologist ___Labor Affiliated Professional ___Lawyer ___Management Specialist ___Occupational Medicine ___Physician (non-psychiatrist) ___Policy Maker ___Psychiatrist ___Psychologist ___Public Health Specialist ___Social Worker ___Higher Education ___Nurse ___other:_____________________
7.	Please check major affiliation: ___Hospital/Health Care Industry ___Nonprofit Organization ___Private Industry ___Private Practice ___Public Health Agency ___University ___Government Agency ___Labor Organization ___Other________________________________

I hereby certify that this proposal has not been submitted to any other conference or meeting and that all participants named have agreed in writing to participate.

Signature___________________________________________________________Date:______________________

Enclosure checklist:

___6 Copies of Proposal Cover Sheet (for each presenter)

___6 copies of a summary (attached to proposal cover sheet)

___2 self-addressed, 1st class stamped envelopes (U.S. Participants only)