Moderator * I attest that participants were reminded of their commitment to strict confidentiality related to all matters discussed. Confirm NONDISCRIMINATION AND CONFIDENTIALITY STATEMENT As a participant of the Interstitial Lung Disease Case Review Conference involved in the evaluation and improvement of quality of care and service, I recognize that confidentiality is vital. Therefore, I agree to respect and maintain the confidentiality of all discussions, records and information generated in connection within the Interstitial Lung Disease Case Review Conference and to make no voluntary disclosure of such information except to persons authorized. As a participant of the Interstitial Lung Disease Case Review Conference, I will ensure that my participation in the peer review process and discussions will be made in a non-discriminatory manner and will not be made based on the patients' race, ethnic/national identity, gender, age, sexual orientation, or patient population for which they serve.DISCLOSURE STATEMENT Jacky Bruce Blank, M.D. moderator of this educational activity, has no financial relationships with ineligible companies* to disclose.Jorge Pena, RRT-ACCS, NPS, BSRC and Maylen Rodriguez, BAS, RRT-CPFT, interprofessional coordinators of this educational activity have no financial relationships with ineligible companies to disclose.Non-faculty contributors and others involved in the planning, development, and editing/review of the content have no relevant financial relationships with ineligible companies* to disclose. *Ineligible Companies - Companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Verbal Disclosures: * Yes No Participants with verbal disclosures: Meeting Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Case Topic * Case Review * Identified incorporable learnings * Case Assessment: Practice Gap(s) and Performance Change(s) Identified Practice Gap(s) * Identified reasons for the practice gap(s): * Identified performance changes to be implemented: * Identified factors facilitating or barriers hindering implementation in practice: * Leave this field blank
