ATC 2004 - SPEAKER DISCLOSURE FORM
   
   
Please note that the following form has eight steps that are required for completion, including the submission of your professional resume or curriculum vitae as a file upload. Please be sure that you have access to the file on your computer before beginning, as the form cannot be submitted without it.
    
   
Presentations must give a balanced view of therapeutic options. Faculty are asked to use generic names to contribute to this impartiality. If trade names are used, those of several companies should be used rather than only that of a single company. (SCS-3-a). In designing educational presentations, the speaker shall assure that the presentation is free of commercial bias for or against any product and, if the presentation is concerned with commercial products, the speaker must present objective information about those products, based on scientific methods generally accepted in the medical community. (SCS-1-a). When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity, the speaker shall disclose to the audience that the product is not labeled for the use under discussion or that the product is still investigational.

ACCME requirements for faculty disclosure are applicable to faculty relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity. (2000-B-14) Information that a faculty member has no significant financial relationships to disclose and information that a faculty member has refused to disclose if there are any significant financial relationships must be provided to the learner. (1999-A-16 & 1999-A-17)

    
   
     
step 1 Title of Presentation  
       
step 2 First and Last Name
 
Email Address  
  Degree and Credentials
  Address
  City/State/Zip
  Phone
  Present Position and Employer
  Describe your expertise in this topic
     
step 3 Educational History Include basic preparation through highest degree held, do not simply list your highest degree
Degree Major Area of Study Institution / School Year Awarded
  Use the space below to briefly describe your professional experience or areas of expertise related
to your involvement in continuing education and your particular role as a presenter for this activity.		  
   
       
   
   
step 4 Presentation Information
1  Please list 1-3 learning objectives, in the order they will be covered during your presentation. Please keep in mind that they must be stated from the perspective of what the participant will be able to do after attending the presentation, and not from the perspective of what you as the presenter will do during the presentation. Be sure to begin each with a verb that denotes an observable action, such as “list, explain, summarize, discuss, compare”, etc, and avoid words that indicate emotions, feelings or other things that occur in the head, such as “know, learn, appreciate, understand, recognize”, etc.
2 List the specific presentation topic(s) that are linked to each objective.
3 Indicate the amount of time, in minutes, that will be used to cover that content.
4 List the teaching method(s) used to deliver that content.
 
Objective Topic Time Method
   
   
   
step 5 Do you have significant financial interest or relationship with any commercial supporters of this CME activity?
Yes
No
 
    Commercial Supporters Include:
Fujisawa Healthcare, Inc.
Roche Laboratories, Inc.
Wyeth Pharmaceuticals
Novartis Pharmaceuticals Corp.
Pfizer, Inc.
SangStat
Genzyme
Bristol-Myers Squibb, Company
Enzon Pharmaceuticals, Inc.
MedImmune, Inc.
ViraCor Laboratories
  
step 6 Do you have significant financial interest with the manufacturer or provider of any product or service you
intend to discuss in your presentation?
Yes
No
     If you answered yes to Questions 5 or 6, please complete this section:     
     Organization    Relationship        
       
       
       
       
       
       
       
step 7 Will you be discussing any unapproved, off-label or investigational uses of a product during your presentation?
Yes
No
     If you answered Yes to Question 7, please complete this section:  
     Product    Use  
       
       
       
       
       
       
   
step 8 As part on the accreditation process we need to have a copy of your professional resume or curriculum vitae (CV) on file for our records. Please use the Browse button below to locate the file on your computer for the upload process.
Microsoft Word is the preferred file format.
   
   
       
  File Location:    
   
   
     
       Please be patient, the file upload process may take a few minutes.
   
         
   
Let us know if you require accommodations as required by the Americans with Disabilities Act.
    
Questions? - Please contact renee@cmehelp.com

© 2003 Amedco LLC