Society of Behavioral Medicine Annual Meeting

	Society of Behavioral Medicine Annual Meeting April 13 - 16, 2005 SPEAKER DISCLOSURE FORM

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)

First and Last Name

Email Address

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.

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

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 3 or 4, please complete this section:

Organization

Relationship

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 5, please complete this section:

Product

Use

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.
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