Miami Neuro Symposium Faculty Planning Form with Video Consent

Course Title *

Please list the course 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.

I will use generic names whenever possible.

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 protected heath information (PHI), individually identifiable health information 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.

I have cited all images, charts and graphs.

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 e-Poster 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 *

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. *

Please sign your name.

Email *

Date *

Month

Day

Year

Need to contact us?

Baptist Health CME
8940 North Kendall Drive
Suite 702E
Miami, FL 33176

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

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Miami Neuro Symposium Faculty Planning Form with Video Consent