ADMSEP 2013 Presenters Application:  BIOSKETCH AND DISCLOSURE Form

All persons in all presentations must complete the entire form below [if you are looking for the Abstract form, go here]. 
 

Contact info (required, all persons
, all presentions)
 
Last Name Phone (e.g. 223-446-5000)
First Name Fax (e.g. 223-446-5000)
Title (MD, PhD, Ed.D. etc) Email
Institution Name:    
Street Address    
Address (cont)    
City/Province    
State    
Zip    
       


Biosketch  (required, all persons, all presentions)
Please enter a brief biosketch below.  An example of can be seen here.  While you may cut and paste from another document into the box below, but please realize all tables, tabbed columns and formatting will be lost.  Thus we would suggest you not cut and paste from you CV.  Besides, the details of a typical CV are not necessary.


 


Disclosure Statement (all persons in every presentation must complete)

CENTER FOR CONTINUING EDUCATION
and
COLLEGE OF NURSING – CONTINUING NURSING EDUCATION
CONFLICT OF INTEREST DISCLOSURE FORM
Author/Editor/Moderator/Planner/Presenter/Peer Reviewer  

SECTION 1 (required reading):
In compliance with the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support of Continuing Medical Education, and the American Nurses Credentialing Center (ANCC) requirements, it is the policy of the UNMC Center for Continuing Education and UNMC College of Nursing Continuing Nursing Education to ensure balance, independence, objectivity, and scientific rigor in all UNMC CCE and UNMC CON CNE sponsored continuing education (CE) activities.
All persons involved in the planning/content development are expected to disclose all relevant financial relationships with pharmaceutical companies, biomedical device manufacturers or distributors, or others whose products or services may be considered related to the subject matter of the educational activity.
Disclosure of these relationships will be included in all written activity materials, and mentioned verbally at the activity so that participants may formulate their own judgments in interpreting content and in evaluating recommendations.
Failure or refusal to disclose will prohibit author/editor/moderator/planner/presenter from presenting at or participating in the planning of this activity.

SECTION 2 (required input):
Please provide the following information regarding financial relationships that you or your spouse/partner currently hold, or have held within the last 12 months with commercial interests that manufacture or provide goods or services which are related to the subject of your presentation/participation in this activity.
I/We have no financial relationships with a commercial entity producing healthcare related products and/or services. (PROCEED TO SECTION 4)
The commercial entities with which I/we have financial relationships do not produce healthcare related products and/or services relevant to the content I am planning, developing, or presenting for this activity. (PROCEED TO SECTION 4)
I/We have financial relationships with commercial entities that produce healthcare related products and/or services relevant to the content I am planning, developing, or presenting for this activity.  (PROCEED TO SECTION 3)
   
   
SECTION 3:  (Please complete if applicable)

COMMERCIAL INTEREST
Name of Company
NATURE OF RELEVANT FINANCIAL RELATIONSHIPS
Please identify the nature of each relationship, using the list below
1. 
2. 
3. 
4. 
5. 

NATURE OF RELEVANT FINANCIAL RELATIONSHIP:  Employee, Grants/Research Support Recipient, Board Member, Advisor or Review Panel Member, Consultant, Independent Contractor, Stock Shareholder (excluding mutual funds), Speakers’ Bureau, Honorarium Recipient, Royalty Recipient, Holder of Intellectual Property Rights, or Other.

Additional information you wish to supply (optional):

 

SECTION 4 (required input):

INVESTIGATIONAL/OFF-LABEL USE OF DRUGS DISCLOSURE 

Are you planning to discuss or reference investigational or off-label use of therapeutic agents or products in your presentation?
No
Yes (please supply information to be discussed and method to inform learner in block below)

 


SECTION 5  (required input):

Please initial each statement below to indicate your willingness to comply.  If the statement is not applicable, please write N/A.

     I have disclosed to the UNMC CCE and UNMC CON CNE all relevant financial relationships, and I will disclose the information to learners verbally (for live activities) and in print.

    The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest.  Content for this activity, including any  presentation of therapeutic options, will be well-balanced, evidence-based, and unbiased.

    I have not and will not accept any honoraria, additional payments, or reimbursements beyond that which has been agreed upon directly with the UNMC CCE and the UNMC CON CNE. 

    I understand that the UNMC CCE and/or UNMC CON CNE may need to review my presentation and/or content prior to the activity.  Hence, I will provide educational content and resources in advance as requested.

   If I am presenting at a live event, I understand that a CME monitor will be attending the event to ensure that my presentation is educational, and not promotional in nature.

   If I am providing recommendations involving clinical medicine, these will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.  All scientific research referred to, reported, or used in CME in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection, and analysis.

   If I am discussing specific health care products or services, I will use generic names to the extent possible.  If I need to use  trade names, I will use trade names from several companies when available, and not just trade names from any single company. 

   If I am discussing any product use that is off-label, I will disclose during the presentation that the use or indication in question is not currently approved by the FDA for labeling or advertising.

   If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.

   If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.

   I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).


SECTION 6  (required input):
DECLARATION


-I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development, or presentation of this CME activity. 
-I will support content and clinical recommendations with the best evidence available from all sources. 
-I will inform learners when I discuss or reference investigational or off-label use of therapeutic agents or product

   By checking this box, I signify that I understand the above in its entirety and agree to the declarations above

  Date

  




WRAPPING IT UP

Optional:  Special note I wish to make at this time:


Important: 
-In all instances of form submission, always include your name in the "contact information" section at the top of the form! 

Prove you are not a robot spammer

Now click submit below
       


Please note:
-After clicking submit, you should see a web page which notes your responses; at this point you are done. 
-However, if you see that you made a mistake at the confirmation page, simply click the "back" button on your browser, make the correction(s), and click submit again (it will be clear from the timestamp which submission is your final version).  You do not have to reenter all the info just to correct a mistake as the form "remembers" what you put in previously.
-You should recieve a confirmation email which includes your submission content.
-After clicking submit, you may wish to procede to the 2013 Meeting Abstract form.
-All relevant components must completed by all presentation participants by the deadline noted elsewhere

Questions/Help? 
-About the application process:   Dr. Gary Beck.
-If you have a question about the form itself, please contact webmaster.



r11/28/12