CME Planning Guide - Faculty Planning Form

Faculty Planning and Attestation Form

Expand each section below to review the required fields. After reviewing each section, please submit the Faculty Planning and Attestation Form.

Faculty Information

Course Name *

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

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.

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

Phone: 786-596-2398
Fax: 786-533-9821
Email: [email protected]

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CME Planning Guide - Faculty Planning Form

Faculty Planning and Attestation Form

A. Unbiased and Independent Content

B. Presentation Guidelines:

C. HIPAA & PHI (Protected Health Information) Laws

D. Copyright/Fair Use Laws

E. Unlabeled / Unapproved Use

Need to contact us?