HGF CME PRESENTER/MODERATOR FORM

INSTRUCTIONS: Enter the information requested below

PRESENTER/MODERATOR INFORMATION

FINANCIAL DISCLOSURE (To be completed by speaker/presentor, moderator, author, or others who may control educational content! Please disclose all

"Financial Relationships" that you have had is the past 24 months with ineligible companies. For each financial relationship, enter the name of the ineligible company and the nature of the financial relationships). There is no minimum financial threshold. We ask that you disclose all financial relationships, regardless of the amount and regardless of the potential relevance of each relationship to the education.

"Relationship types including but not limited to employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator ever if that individual's institution receives the research grant and manages the funds. Within the past 24 months, have you had a financial relationship in any amount with an entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients?

Within the past 24 months, have you had a financial relationship in any amount with an entity whose primary business is producing,marketing, selling, re-selling, or distributing healthcare products used by or on patients?

LEARNING OBJECTIVES (Does not Apply to Moderators)

Please provide your action-oriented objectives for your presentation. Describe changes to skills and abilities (competence), the medical practice (performance), & patient outcomes rather than just changes to knowledge.

Finish this sentence for each criterion:

As a result of my presentation, learners should be able to:

ATTESTATIONS: Please read the following attestations.

By signing you agree to abide by the policies and regulations addressed in this form.

• I will ensure that the content for this activity, including any presentation of therapeutic options, will include recommendations for patient care based on current science, evidence, and clinical reasoning while giving a fair and balanced view of diagnostic and therapeutic options. 

• I will ensure that all scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation conforms to the generally accepted standards of experimental design, data collection, analysis, and interpretation. 

• I will ensure that new and evolving topics in CME are clearly identified as such within the presentation(s) without advocating for or promoting, practices that are not or not yet adequately based on current science, evidence, and clinical reasoning. 

• I will not advocate for unscientific approaches to diagnosis or therapy, nor manners of practicing healthcare that is determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients. 

• I will ensure that the presentation of the information will promote quality or improvements in healthcare and will not promote a specific proprietary business interest or ineligible company. 

• The accredited education I provide will serve to maintain, develop, or increase the knowledge, skills & professional performance & relationships that a physician uses to provide services for patients, the public or the profession. 

• The education I provide will be fair and balanced and any clinical content supports safe and effective patient care. 

• The accredited education I provide in my educational materials (slides, abstracts, handouts, etc.) will be free of marketing or sales of all products/services including logos, trade names, or product group messages, and I will not actively promote or sell products/services that serve my professional interests. 

• I verify that prior to the presentation; I have requested and/or obtained permission from copyright holder(s) to reproduce/copy, from their work, the portions of my presentation that are protected by copyright laws. I acknowledge that the Human Growth Foundation will not be held legally responsible for any misrepresentation on my part regarding copyright infringement. 

• If presenting specific patient cases or case histories, I attest that I have HIPAA-compliant authorization for any PHI (Protected Health Information) in the presentation materials or have de-identified all materials to the extent possible in adherence to my organizational and state laws. Educational activities happening off-campus (UTMC) must be completely deidentified. 

  
  

  1. acknowledge that the Human Growth Foundation or its designees may request to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance following all deadlines as requested. 

  2. acknowledge that the Office of CME may have someone attend or monitor the activity to ensure that the presentations, 

     educational materials, and activity are educational, not promotional in nature. 

  3. hereby consent to the duplication of my presentation and to its inclusion in the course handouts and in any enduring materials 

     maintained in connection with the course in any format or media whatsoever. 

  4. acknowledge that continuing education accreditation guidelines prohibit me from accepting any reimbursement (honoraria, additional pay, reimbursements, financial gifts, or in-kind exchange) for this presentation from any source other than the Human Growth Foundation or the organization for which I am presenting. 

• My disclosure provided above is accurate for the past 24 months. 

• My financial relationships will not influence or bias the education at this activity. 

• I will contact the HGF Office of CME if there are any changes to my financial relationships prior to the start of the activity. 

• By typing or signing my name below, I attest that the above information is accurate and complete, and I agree to comply.