MCI Rad Onc GR_Speaker Confirmation and Faculty Planning Forms with Disclosure and Video Consent

Baptist Health, through its nationally accredited Continuing Medical Education Program, maintains compliance with the ACCME's Policy on Clinical Content Validation and the Standards for Integrity and Independence. Additionally, we are responsible for compliance with laws related to copyright/fair use, HIPAA and Protected Health Information. To that end, we are obliged to resolve any conflicts of interest and to review course content prior to the educational course. We request your prompt completion of this attestation form.

If you have questions or changes related to CME management of this symposium, please contact me at 786-596-2398.

Speaker Stipend: Baptist Health South Florida will pay you a speaker stipend of $1500 and a travel stipend of $600 for air and ground transportation and meals. No additional expense reimbursement.
Hotel Accommodations and Resort Fees: A reservation will be made for you at the Hilton-Miami Dadeland on the evening of Thursday, December 5, 2019, and your confirmation number will be sent to you. Baptist Health will pay for your hotel and resort fees directly for one night. If you wish to extend your stay, additional nights will be at your expense.
Hotel Parking: Daily parking rates at the hotel will be paid for directly by Baptist Health.

Preferred Lecture Title: *

Faculty Name and Professional Title: *

Please list your name and title as they should appear on the website and other promotional materials.

Mobile Number: *

Please enter your contact information so that we can reach you while you're traveling.

Agreement

A. Unbiased and Independent Content

I agree to uphold academic standards to insure independence and scientific rigor in my role in the development and presentation of this CME & CE activity.

I agree to the following statements: *

All recommendations for patient care in accredited continuing education must be based on current science, evidence and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

All scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.

I will omit company logos and brand names from the educational materials that are part of my CME presentation, such as slides, abstracts and handouts.

B. Presentation Guidelines:

Instead of providing a syllabus, Baptist Health CME provides registered attendees with access to speakers’ presentations in PDF format on a limited access webpage before and after the symposium. Access will be shared only with symposium attendees and faculty and will be available until two weeks after the symposium.

My presentation will include slides for *

Disclosure of Financial Relationships

Learning Objectives,

Summary: Key Learning Points with References

Citations and References (evidence-based, peer-reviewed)

Do you agree to have a PDF version of your presentation posted online and made available to attendees? * *

NOTE: We cannot post presentations which are not compliant with laws related to copyright/fair use, HIPAA or PHI.

Yes

No

C. HIPAA & PHI (Protected Health Information) Laws

It is the responsibility of the faculty to comply with HIPAA laws, and they are liable in case of any privacy breach that violates HIPAA regulations. Faculty members are expected to remove all identifying information from presentation materials. If presentations require the use of patient images for effective teaching, presenters must obtain patient consent as required by HIPAA.

I agree to the following statements: *

I have removed all Personal Health Information (PHI) or de-identified images used in my materials including photographs as well as dates of patient care or birth dates (typically found in the margins of clinical images).

When presenting specific patient cases or case histories, I warrant that I have obtained HIPAA compliant authorization for any PHI in my presentation materials.

If my presentation will contain patient identifiers, it is my responsibility to obtain consent from my patients for use of their PHI, including photographic images.

D. Copyright/Fair Use Laws

I agree to the following statements: *

I have obtained permission from copyright holder(s) to reproduce/copy from their work. I acknowledge that Baptist Health South Florida (BHSF) will not be held legally responsible for any misrepresentation on my part regarding copyright infringement.

E. Unlabeled / Unapproved Use

Although accredited continuing education is an appropriate place to discuss, debate, and explore new and evolving topics, these areas need to be clearly identified as such within the program and individual presentations. It is the responsibility of accredited providers to facilitate engagement with these topics without advocating for, or promoting, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning.

I agree to disclose to the audience if my presentation includes information about a product not labeled by the FDA for the use under discussion or that is still investigational.

My Presentation: (check one) *

Select one.

DOES NOT include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose.

DOES include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose.

F. Baptist Health CME Portal Learning Management System Consent to Video

I, the undersigned, do hereby voluntarily participate and give authorization for myself to appear in filming, photographs, videotaping, audiotaping and/or interviews for medical, clinical, and hospital education and training. I do hereby consent to the specific use of such production, which includes my name, likeness, and the content I present, for continuing medical education.

I do hereby release Baptist Health South Florida, its agents, and its employees from all liability in connection with the above-referenced educational content. I waive any right to inspect or approve the finished product or the advertising or other copy that may be used in connection with the educational content produced. I hereby consent to the use of such content for continuing medical education, without expectation of remuneration to me now or in the future, and this shall be binding upon my heirs, personal representatives and assigns.

Specific Use: The video and/or audio recording will be used strictly for non-profit educational purposes of the Baptist Health South Florida Continuing Medical Education Department described above. It will not be sold to a third party, individually or in combination with other presentations, as an educational tool now or anytime in the future.

Please Initial *

Disclosures

Baptist Health South Florida, an ACCME accredited CME provider, operates within the framework of the Standards for Integrity and Independence in Accredited Continuing Education to insure balance, independence, objectivity and scientific rigor in all of its CME activities. Anyone engaged in content development, planning, review or presentation is obliged to complete this form. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.

Circumstances create a conflict of interest when an individual has an opportunity to influence or control CME content about products or services of an ineligible company with which he/she has a financial relationship.
The ACCME defines an “ineligible company” as any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
ACCME requires that faculty disclose all financial relationships that you have had in the past 24 months with ineligible companies.

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s).
There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.
NOTICE: Please do not disclose actual financial value of affiliations. Diversified mutual funds are not included in the definition of "commercial interest".

Please check the option that applies to you. *

I, the undersigned, have not had any financial or other relationship(s) with an ineligible company (as defined above) now or within the past 24 months.

Within the past 24 months, I, the undersigned, had a financial relationship, arrangement and/or affiliation with the organizations or companies noted below.

Indicate below the company(ies) with which you or your spouse/partner have (or had) financial relationships and your role, affiliation or financial interest with that company. *

NOTE: Please do not disclose actual financial value of affiliations. Diversified mutual funds are not included in the definition of "commercial interest."

I have received grant/research support from: *

I am a consultant for: *

I am a contractor for: *

I am an advisor for: *

I am an employee/owner of: *

I am an executive of: *

I am the owner of: *

I receive royalties or am a patent beneficiary from: *

I am on the speakers' bureau for: *

I own stock in or am a shareholder of: *

I have other relevant financial relationships to disclose: *

Attestation

I attest that the information provided above is true and correct and that I have read and agree to all the terms of this Invitation as stated and described herein. Other Payments: Your acceptance of this invitation is contingent on the stipulation that you agree that you will not accept any other payment related to your participation in this CME activity. *

Please sign your name.

Email *

Date *

Month

Day

Year

Need to contact us?

Baptist Health CME
Baptist Health Education Center
Baptist Hospital
8900 North Kendall Drive
Miami, FL 33176

Phone: 786-596-2398
Fax: 786-533-9821
Email: CME12@BaptistHealth.net

You are here

MCI Rad Onc GR_Speaker Confirmation and Faculty Planning Forms with Disclosure and Video Consent