SPEAKER FORM - Disclosure & Faculty Agreement
Speaker Name *
Email Address *
Required entries with every submission*
FACULTY DISCLOSURE See Faculty Disclosure Statements
It is the policy of the GCEP to comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards for commercial support of CME activities. 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 GCEP 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 emergency medicine products or commercial emergency medicine 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
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.
FACULTY AGREEMENT
The undersigned Faculty (the “Undersigned”) agrees to:
1. Present the session as specified in the course objectives and in the marketing materials of the Georgia College of Emergency Physicians (GCEP).
2. Submit all handouts (if providing) and related materials for the session in accordance with submission deadline and requirements.
3. Not engage in any type of promotion, marketing, or selling of any product or service during the presentation which shall in all respects be free of commercial bias.
4. Notify GCEP’s Meeting and Education Manager immediately in the event that an emergency prevents the Undersigned from meeting his/her obligations as a speaker.
5. Authorize GCEP to use the Undersigned’s name, likeness, photographic image or biographical data in connection with the use and promotion of the meeting and the presentation.
I have read the Disclosure Requirements and Faculty Agreement 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 or the faculty agreement, when known and deliberate, may result in disqualification for two years in similar educational or related activities.
Entering your name in the following space acts as my signature and agreement to the above statement:
