IIRRM Congress Faculty Form - The International Clinical & Scientific Congress for Restorative Reproductive Medicine

Full Name:

Degrees or professional affiliations and designations

Email

Phone Number

Please select all that apply:

Title of Presentation(s):

Please indicate if you serve in any of the following positions as a trustee or a board member, either appointed in full or serving as in-term until the position is filled

You indicated you serve in another executive role as a trustee or board member. Please enter this role above.

1. Do you or does any member of your immediate family have a financial relationship or interest with any proprietary entity producing health care goods or services?

Yes
No

Please check the relationship below:

Please indicate the names of all organizations in which you have a financial relationship or interest and the specific clinical areas that correspond to the relationship.

1b. If not already reported above, please select if you are in receipt of any of the following, or have any other potential conflict(s) of interest to report:

Receipt of grants/research supports
Receipt of conference honoraria or speaker stipend
Participation and/or employed in a company sponsored speaker’s bureau
Other support

Please specify, and if applicable, state the name of the commercial company:

2. Have you receive an honorarium, consulting fee, or any other type of compensation from a proprietary entity producing health goods or services that relate to the topic of your presentation?

Yes
No

3. Have you participated in any speaker training related to your topic?

Yes
No

4. Will your presentation include slides or printed materials provided by a proprietary entity?

Yes
No

5. The content of my material(s)/presentation(s) in this CME activity will include discussion of unapproved or investigational uses of pharmacological, biological, and medical products or devices. This includes the off-label use of pharmacological drugs.

Yes
No

If the answer to any of the questions 2-5 is “yes,” please provide pertinent details below.

6. Please list 2-5 learning outcomes that attendees will gain from your presentation ?

For an explanation and examples of developing learning outcomes for CME please view this link: http://iirrm.org/learning-outcomes/.

7. I give permission to video record my presentation for posting to the conference website for educational purposes, which will is protected by a paywall.

Yes
No
Yes, with conditions

Please note conditions or concerns below

8. I acknowledge that I will retain all copyright in relation to the text and graphics contained within my presentation, and I consent to the presentation being distributed by IIRRM in the form of electronic files, including PDF slide handouts and the recorded presentation to the IIRRM website, and to copy the electronic documents for distribution and presentation at the conference.

Yes
No
Yes, with conditions

Please note conditions, concerns or restrictions of use/distribution below

I have answered these questions to the best of my knowledge. If I have a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require the conference comittee to identify a replacement.

Clear Signature

By signing above, I acknowledge and agree to the above terms of acceptance.

21st International Clinical & Scientific Congress for RRM

Faculty Form