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North American Regional Conference Presenters

11 March 20191 June 2020

Presenter Full Disclosure

Form for CME Activities

All speakers, facilitators, instructors and presenters are required to submit a faculty disclosure form (see below) with regard to presentations at any IIRRM-A hosted conference, in accordance with requirements for CME accreditation. Disclosure must be made to the audience indicating whether you have or have not had relationships with for‐profit or not‐for‐profit organizations within the past 2 years.

In additional all speakers/faculty must disclose to IIRRM and learners when an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose, is discussed during an educational activity. Speakers/Faculty must disclose that the product is not labeled for the use under discussion or that the product is still investigational. The intent of this policy 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.

The conference planning committee reviews the disclosure forms for any Conflict of Interest (COI). All disclosures are made available to participants. IIRRM's full policy and procedures for managing conflicts of interest can be viewed here. If you have any questions or concerns please contact Kathleen at kathleen@iirrm.org.

The following form is for virtual presentation at the North American Regional Conference for Restorative Reproductive Medicine being held on July 22, 2020 .

Title of Presentation(s): *

Name of Presenter: *

Titles, Degrees *

*This will be listed in the conference program

Phone Number *

Email *

1. Do you or does any member of your immediate family have a financial relationship or commercial interest with any proprietary entity producing health care goods or services? *

(A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services. This includes online services, programs and material)

If yes, please check the relationship below:

Research Grants
Speaking or Presenting
Ownership
Consultant for fee
Employment
Partnership
Stock/ Bond Holdings (excluding mutual funds)
Other: Please describe in the space provided 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, medication or devices. This include "off-label" uses of FDA approved drugs. *

* Please identify to the audience at the start of your presentation the unapproved or investigational product or device. This can also be done on the second slide of your presentation.

If the answer to any of the questions 2-5 is “yes,” please provide pertinent details below.

6. Please list 3-5 learning outcomes that attendees can expect to gain from your presentation (we require these for CME accredtiation) ?

For an explanaton and examples of devloping leanrng outcomes for CME please view this link: https://iirrm.org/learning-outcomes/

7. I give permission for IIRRM to video record my presentation for posting to the IIRRM website for educational purposes. *

8. 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 or handouts, to the IIRRM website, and to copy the electronic documents for distribution which may include flash drives and downloadable files. *

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 International Institute for Restorative Reproductive Medicine to identify a replacement. *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Date Signed

Journal Nook

La divulgación completa del presentador

Advancing Excellence in Restorative Reproductive Medicine

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