Speaker Requirements Department Coordinator

Transcription

1 UC Davis Health System Office of Continuing Medical Education (OCME) 3560 Business Drive, Suite 130, Sacramento, CA (916) phone (916) fax Distance Education Coordinator: Gwenn Welsch Grand Rounds (RSC) Coordinator: Pamela Schneider Speaker Requirements Department Coordinator Event will be teleconferenced Event will be video taped (If checked, Speaker Release Form must be completed and submitted.) Speaker Packet should include: 1. Speaker Information Sheet 2. ACCME accreditation guideline 3. Full Disclosure Declaration Form 4. Speaker Release Form (only needed if event will be video taped) Presentation: 1. A computer is available in the PSSB Auditorium Sound is not available from this computer If using embedded videos please test before presentation 2. Personal computer may be used If using a MAC bring an adaptor for a VGA connection Come early to test computer/presentation/sound/embedded videos If you have sound the cordless mic can be used to pick up sound. 3. Disclosure Remember to add a disclosure slide in the beginning of presentation. Speaker must give a verbal disclosure at the beginning of presentation. 4. Question and Answers Remote site are seeing the event, please invite sites to ask questions. Remember to repeat audience questions so remote sites can hear the question and so the question can be heard on the video. Speaker Packet needs to be completed before event to receive CME credit. Packet due by: Mail/Fax Completed packet to:

2 UC DAVIS HEALTH SYSTEM, CONTINUING MEDICAL EDUCATION REGULARLY SCHEDULED CONFERENCE (GRAND ROUNDS) SPEAKER INFORMATION SHEET Speaker: Course Title: Date: Time: Location: Please provide the following information regarding your presentation: AUDIO-VISUAL EQUIPMENT NEEDS: Please check all equipment needed: Power Point Computerized Slide Presentation Version 2003 on PC's Laptop and LCD Projector Laser Pointer Overhead Projector Whiteboard, pens & eraser Single Slide Projection Other NONE PRESENTATION/HANDOUT: I have included my syllabus contribution. CURRICULUM VITAE (CV) UCD staff do not need CV I have included my current CV I have already sent my current CV DISCLOSURE STATEMENT: (Form Attached) I have included my Full Disclosure Declaration AND I will have a disclose slide in my presentation AND I will verbally disclose at the podium at the beginning of my presentation SPEAKER RELEASE FORM (only needed if event is filmed) I have included my Speaker Release Form Title of presentation: Professional title of speaker: Course objectives (at least 3 objectives per hour of presentation): Teaching methods: (check all that apply) didactic lecture discussion workshop case presentations demonstration other Brief summary of content: Phone: FAX : address: Mailing address: RETURN THIS FORM TO:

3 UC Davis Health System Continuing Medical Education Accredited by the ACCME Accreditation Council for Continuing Medical Education NEW GUIDELINES In response to the updated 2004 ACCME Standards for Commercial Support effective September 2004, UCDHS CME policy requires faculty to give both written and verbal disclosure. Standard 2: Resolution of Personal Conflicts of Interest: Q 2.1 Provider must be able to show that everyone who is in a position to control the content of an education activity has disclosed all relevant (occurring within the past 12 months) financial relationships with any commercial interest to the provider. All course chairs, co-chairs, presenters, moderators, panel members, or others involved in planning course content must complete the disclosure form. Completed disclosure forms are used to prepare a disclosure statement that is included in course handouts or displayed in the registration area to inform course participants about potential conflicts of interest. Conflict exists when the speaker has a financial interest in a company and the opportunity to affect the CME content about that company s product or service. Q2.2 An individual who refuses to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME and cannot have control of or responsibility for the development, management, presentation or evaluation of the CME activity. Q2.3 Providers must have a mechanism to identify and resolve all conflicts of interest prior to the education activity being delivered to learners. Below is an example of a PowerPoint disclosure slide that will be inserted in your presentation as a prompt for your verbal disclosure. Or, you may choose to prepare your own detailed slide (see example) listing information related to your financial interest/affiliation or off-label use of products and/or devices to be discussed in your presentation. STANDARD 6: Disclosures Relevant to Potential Commercial Bias Q6.1 An individual must disclose to learners any relevant financial relationship(s) to include the following: name of the individual, name of the commercial interest(s), nature of the relationship the person has with each commercial interest. Q6.2 For an individual with no relevant financial relationship(s) the learners must be informed that no relevant financial relationship(s) exist. Q6.5 A provider must disclose the above information to learners prior to the beginning of the educational activity. If there is no disclosure slide before the presentation, it is the responsibility of the course chair/moderator to ensure compliance with the ACCME verbal disclosure requirement.. Slide Insert: Example Slide: DISCLOSURE all relevant financial relationships(s) with any commercial interest to the provider name of commercial interest(s) nature of the relationship with each or Name of Organization DISCLOSURE: I have financial interest/arrangement or affiliation with (ie company name) Relationship (ie employee, own stock, honorarium ect.) no relevant financial relationships exist

4 University of California, Davis, Health System Office of Continuing Medical Education FACULTY DISCLOSURE FORM Fax completed form to: It is the policy of UC Davis Health System Continuing Medical Education to insure balance, independence, objectivity and scientific rigor in all CME activities. CME content will be evidence based and free of commercial bias. Anyone engaged in content development, planning or presentation must complete this form. Persons who fail to complete this form may not participate in the CME activity. All identified conflicts of interest will be resolved, and disclosure will be made to activity participants. CME Activity Title: Your role in this CME activity: Presenter Author Course Director Moderator Panel Planning Committee DISCLOSURE Conflict exists when you have a financial interest in a company and the opportunity to affect the CME content about that company s product or service as related to your presentation at this activity. Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with the manufacturer of the products or services that will be discussed in this CME activity? NO Skip to Declaration section YES Please list your disclosures and resolutions below Commercial Interest List Nature of Relevant Financial Relationship Examples: Recipient of grants/research support, honorarium, royalty; employee, consultant, speakers bureau, board member, advisor or review panel member; Company independent contractor; stock shareholder (excluding mutual funds); holder of intellectual property rights, or other (identify) RESOLUTION OF CONFLICT OF INTEREST Please indicate below how the conflict of interest will be resolved. Presenters, Authors, Course Directors, Moderators, Panel Members: I will support my lecture and clinical recommendations with the best available evidence from the medical literature. I will refrain from making recommendations regarding products or services, e.g., limit talk to pathophysiology, diagnosis, and/or research findings. I will recommend an alternative speaker for this topic for the planning committee s consideration. I will submit my talk in advance to allow for adequate peer review. I will divest myself of this financial relationship. As a course chair or planning committee member, to the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias. Planning Committee Members, Meeting Coordinators To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias. I will recuse myself from planning activity content in which I have a conflict of interest. Additional information may be requested to resolve conflict of interest. Disclosure will be made to participants prior to educational activity. DECLARATION I will uphold academic standards to insure balance, independence, objectivity and scientific rigor in my role in the planning, development or presentation of this CME activity. In addition, I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I agree to provide verbal disclosure prior to my presentation at the activity. Please print name: Signature Date Thank you for completing this form. Please return this form to the program organizer. If you have questions regarding the UC Davis Health System CME Conflict of Interest Policy, please call

5 UNIVERSITY OF CALIFORNIA, DAVIS BERKELEY DAVIS IRVINE LOS ANGELES MERCED RIVERSIDE SAN DIEGO SAN FRANCISCO SANTA BARBARA SANTA CRUZ Speaker Release Form This Speaker Release is provided to the University of California, Davis, Health System with respect to the following presentation (the Presentation ): Title of presentation: Title of conference: Type in date of event: (mm/dd/yy) By signing below, I acknowledge that I have read and agreed to the following: I agree to grant, assign and convey to The Regents of the University of California (The Regents ), a California corporation, all rights, title, and interest I may have in and to the Presentation and in and to any still or motion picture or audio recording made there from. I agree to authorize The Regents, free of charge and without limitation, to photograph, record, publish, or otherwise copy such Presentation and to broadcast, display, reproduce, edit, exhibit and distribute the Presentation and any derivative works created from or with it, over television, cable, the Internet or any other communication medium now existing or hereafter created. The Regents also retain the right not to use the footage for anything other than archival purposes. This authorization explicitly includes the use of my name, likeness, voice and/or biographical information for the purpose of publicizing broadcast, telecast, distribution, publication or exhibition of the specified program or portions thereof. The Presentation and any Presentation materials are my own original material or material for which I have full authority to grant the rights set forth in this Speaker Release. This Speaker Release supersedes all prior agreements pertaining to its subject matter and cannot be amended without the prior written agreement of an authorized representative of UC Davis. Signature: Print Name: Date: