Faculty Form

Faculty Form

The Rhinoplasty Society Annual Meeting 2015
May 14, 2015
Palais des Congres de Montreal
Montreal, Canada

INSTRUCTIONS – Before beginning the Faculty Forms below, please be sure you have an abbreviated (4-page max) CV ready for upload. You cannot save the information, once you begin, you must complete all at once.

EXACT TITLES AND DESCRIPTION / CV

THIS FOLLOWING IS TO BE COMPLETED ALONG WITH AN UPLOADED ABBREVIATED (4 page max) CV BY February 15, 2015

* Denotes Required Fields

Speakers Name*:

Board Certification in*:  Plastic Surgery Facial Plastic Surgery Oto/ENT

Phone:

Fax:  

Email*:

Please give EXACT TITLE of your presentation, a one-sentence description and learning objective describing your concept of what the audience is to learn from your presentation. If you are involved as moderator, planner, etc., please specify.

Presentation Title*:

Summary description of your presentation:

Learning Objective:

FACULTY ACCEPTANCE OF RESPONSIBILITY

  • I understand that if I or an immediate family member have or had a financial relationship with an ACCME-defined commercial company currently or within the past 12 month period (or no relationship), it is to be disclosed on the first slide as well as verbally before beginning my presentation.
  • I certify that the appropriate medical/patient releases, for photography and subsequent use in presentations, have been obtained.
  • I certify that all copies of printed material has the permission of the author, and that my use of such material will not violate any copyright laws.
  • I understand that failure to comply may necessitate termination of the presentation.

Electronic Signature*:

AUDIO-VISUAL REQUIREMENTS

ALL PRESENTATIONS MUST BE IN POWER POINT FORMAT

All presentations will be due no later than May 7, 2015. We will use a file sharing program, which will be determined at a later date. Power Point is the only acceptable format and no personal computers will be allowed.

The following A/V equipment will be available in the meeting room:

  • A speaker's standing lecturn with microphone and reading light
  • Laptop computer equipped with Windows 7 (no personal computers will be used)
  • Digital LCD projector
  • Laser pointer with advance/reverse slide controls
  • Large projection screen

Please indicate below if you will require any additional specific items for your presentation so that we may place advance orders for this equipment. Please be sure your list is complete.*

 Equipment is Sufficient Additional Equipment Desired

Please list any extra equipment desired, if any, here:

Electronic Signature*:

Date:

Which Organization do you belong to?*  ASPS ASAPS Other

ASPS - ID#: 

ASAPS - ID#:

Please upload your abbreviated (4 page max) CV here (doc, docx, pdf):

Please click SEND to have your forms sent immediately to the Executive Office before proceeding to the Disclosure Form.

STOP !!! Please be sure you click the send button above to be sure your form and CV are sent to the executive office. THEN, please proceed to the ASAPS disclosure below.

DISCLOSURE FORM

The Rhinoplasty Society in conjunction with the Aesthetic Society is required to ensure balance, independence, objectivity and scientific rigor in its live activities. ASAPS has an online disclosure system which collects disclosures from all ASAPS-related faculty and planners for the year. Follow the link: http://www.surgery-online.org/ASAPSCOI/welcome.aspx

A security system will ask for your login. If you do not know it, please email darlene@surgery.org Once you log in, if the date on the right hand side under your name is after May, 2014, you have already completed the form for this year and you do not need to take any action. However, if there is no date or the date precedes 7/1/14, please open the form and follow the instructions to make your disclosures. This is required of all faculty of Certified Education.

What Must Be Disclosed? Anything of value from an ACCME-defined commercial company, i.e. entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. “Anything of Value” refers to a variety of items, including, but not limited to, an equity position, vested interest, royalties, serving as a consultant, research grant funding, honoraria for education services or to any other relationship you or an immediate family member may have with a commercial company. Conflicts will be addressed in accordance with the ASAPS Conflict of Interest/Disclosure Policy.

All faculty with The Rhinoplasty Society are to disclose to the audience any financial relationship (or no relationship) on the first slide of their presentation, as well as, verbally before beginning the educational activity. It is your responsibility to maintain objectivity and balance in the presentation of scientific information. Presentations must give a balanced view of the therapeutic options. Faculty use of generic terms will contribute to this impartiality. If trade names are used, those of several companies should be used rather than that of a single supporting company. When an unlabeled use of a commercial product or an investigational use not yet approved for any purpose is discussed, you need to disclose that the product is not labeled for the use under discussion or that the product is still investigational.