CME Meeting Speaker Form

Details
Speaker Name:*
Email Address:*

Contact Information
Please list how you wish to be listed in the program:
Mailing address:
Office Phone:
Mobile Phone:
Home Phone:
Fax:
Assistant's Name:
Assistant's Phone:
Assistant's Email Address:

Bio
(used in the Meeting Program and excerpts taken for verbal introduction)

Educational Objectives
The AADDS Education Committee has provided you with basic objectives for the topic(s) that you will be presenting. As an expert in the field however, please expand upon the provided objectives by completing this form.  Objectives are not expected to be exhaustive.  They should make clear the knowledge, skills or attitudes that will be gained by the participant. 

Title of Presentation 1: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)


Title of Presentation 2: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)


Title of Presentation 3: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

In an effort to focus our funding efforts, please assist us by listing companies that might find your topic(s) of interest and might want to support the meeting financially:

Handouts
I will mail / have already mailed a CD of my handouts to Atlanta Assocation for Dermatology and Dermatologic Surgery - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092

I will email / have already emailed my handouts to maryann@theassociationcompany.com

Audio Visual Requirements
I will need the following equipment for my presentation(s):

LCD Projector/Wireless Remote/Laser Pointer
One 35mm slide projector
Two 35mm slide projectors
Video Player - 1/2" tape
Video Player - 3/4" tape
Overhead Projector
Whiteboard and markers, colors: 
Flip chart and markers, colors: 

Other AV needed:

I will be presenting via Microsoft Power Point (a laptop will be provided)
I will be presenting via Apple Keynote or other software (speaker must provide laptop to run onsite)
I require only voice amplification OR  my presentation(s) will include sound beyond my oration.
I have integrated video into my presentation file (speaker must provide laptop to run onsite)

Travel
I reside in Atlanta, (skip ahead to FACULTY DISCLOSURE)

I am DRIVING to and from Atlanta from out of town (skip ahead to ACCOMMODATIONS)

I am FLYING to and from Atlanta (please complete Arrival/Departure info below)

ARRIVAL
I DO / I DO NOT wish to be shuttled from the airport to the hotel
Airport
Airline Flight Number
Arrival date Arrival Time
 
DEPARTURE
I DO / I DO NOT wish to be shuttled from the airport to the hotel
Airport
Airline Flight Number
Departure date Departure Time

Accommodations
I do NOT need accommodations in Atlanta

Please reserve accommodations for me in Atlanta

I will be checking in on

I will be checking out on

Faculty Disclosure
It is the policy of the AADDS to comply with the Accreditation Council for Continuing Medical Education (ACCME) Statndards for commercial support of CME activities.  A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. All faculty are required to disclose to the program audience any real or apparent conflict(s) of interest related to this meeting or its content.  Having an interest in or affiliation with the corporate organization does not necessarily prevent you from making the presentation, but the relationship must be made known to the audience.  Failure to disclose or false disclosure will require the AADDS to identify a replacement for your participation.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for you immediate family as defined above.  If an individual is uncertain about what might constitute a potential financial conflict or interest they should err on the side of full disclosure.

Category Code Description
Consultant / Advisor C Consultant fee, paid advisory boards or fees for attending a meeting  (for the past 1 year)
Employee E Employed by a commercial entity
Lecture Fees L Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial entity (for the past 1 year)
Equity Owner O Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial dermatology products or commercial dermatology services
Patents / Royalty P Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant Support S Grant support for the past 1 year (all sources) and all sources used for this project if this form is an update for a specific talk or manuscript with no time limitation.


Please select one of the following two options:

I DO NOT have any financial relationship to disclose.
I have the following financial relationships to disclose:

Company/Organization:

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation (specify drug(s) or product(s) by name for which the unlabeled use will be discussed.

I have read the Disclosure Requirements and to the best of my knowledge, the information provided on this form is true and correct and represents all items for disclosure.  I understand that failure to comply with the disclosure policy, when known and deliberate, may result in disqualification for two years in similar educational or related activities.  I agree to promptly notify the program directors is any of this information changes.



Entering your name in the following space acts as my signature and agreement to the above statement:*