Title of Presentation(s): *
Name of Presenter: *
Degrees, Titles or Professional Affiliations *
Phone Number *
1. Do you or does any member of your immediate family have a financial relationship or interest with any proprietary entity producing health care goods or services?
If yes, please check the relationship below:
Please indicate the names of all organizations in which you have a financial relationship or interest and the specific clinical areas that correspond to the relationship. *
2. Have you receive an honorarium, consulting fee, or any other type of compensation from a proprietary entity producing health goods or services that relate to the topic of your presentation?
3. Have you participated in any speaker training related to your topic?
4. Will your presentation include slides or printed materials provided by a proprietary entity?
5. The content of my material(s)/presentation(s) in this CME activity will include discussion of unapproved or investigational uses of products or devices.
The intent of disclosing the above is not to prohibit or limit the exchange of views in scientific and educational discussions, including discussions of unapproved uses, but to ensure that faculty discloses to learners that such discussion will take place.
If the answer to any of the questions 2-5 is “yes,” please provide pertinent details below.
6. I give permission to video record my presentation for posting to the VitaeCME website for educational purposes only and share educational materials with learners
* A member of the faculty will contact you to work within these limitations if this option is selected.
7. I acknowledge that I will retain all copyright in relation to the text and graphics contained within my presentation, and I consent to the presentation being distributed by IIRRM in the form of electronic files, including slides, audio and video recording to the IIRRM website. This information is made available for educational purposes only and largely will remain limited to current IIRRM members.
I have read the VITAECME Policy and Procedures for Managing Conflicts of Interest, and I have answered these questions to the best of my knowledge. If I have a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require the ViitaeCME to identify a replacement.