Thank you for accepting our invitation to participate on the faculty of the WRA 19th Annual Meeting. Δ 1Speaker Information2Financial Disclosure Speaker InformationPlease complete the information below as you would like it printed in our promotional materials.Name(Required) First Middle Last Credentials (MD, PhD, etc.) Professional Title(s)(Required)Institution / Hospital / Company(Required)Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCĂ´te d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRĂ©unionSaint BarthĂ©lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTĂĽrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweĂ…land Islands Phone NumberCell Phone Number(Required)*Cell Phone Contact for an emergency onlyPersonal Email(Required)To prevent important meeting information from going to your junk/spam folder or being blocked by your institution. Introduction Bio Upload W-9 Form Drop files here or Select files Accepted file types: pdf, Max. file size: 256 MB. Headshot Drop files here or Select files Accepted file types: jpg, png, gif, Max. file size: 256 MB, Max. files: 1. AccomodationsThis field is hidden when viewing the formNights you will be needing accommodation at the conference :(Required) Friday Night Saturday Night Mode of travel to the conference(Required)Will you be bringing any guests?(Spouse & children are welcome!) Yes No Please indicate how many guests in total(Required)Please enter a number less than or equal to 5.Name of your guest(s)First NameLast NameDietary Need (if any) Add RemoveWill you be bringing a dog? Yes No Presentation DetailsTitle of Lecture(Required)Date(Required) Audio / VisualWe ask that you bring your presentation on a UBS Flash Drive. For your presentation, WRA will provide a podium, microphone, screen, LCD Projector, and laptop computer. My presentation includes embedded audio and/or video. Other A/V RequestsObjectivesThe following section MUST be completed for CME documentation purposes. Should this section not be adequately addressed CME for this activity may not be awarded.Title of Presentation(Required)Description of your presentation content (one paragraph maximum) List one recent journal article that gives background on this topic and/or why it is an area that physicians attending this conference need to know: Number of Objectives(Required)Please enter a number from 3 to 3.Objectives:(Required)Please list at least two learning objectives for the presentation. Please focus on competencies attendees will acquire rather than just knowledge-oriented goals. As an example, here's an objective from a previous year's CME application that focuses on how the attendees will be able to apply the content in their practice: "The attendees will be able to integrate new research on gut bacteria in the nutritional guidance given to patients." Use the (+) on the right to add up to three objectives. Add Remove Step 1: Disclosure of All Financial RelationshipsPlease disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition in Glossary of Terms). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, in any amount, with ineligible companies. You should disclose relationships regardless of the potential relevance of each relationship to the education.Glossary of Terms Ineligible company: (formerly known as "Commercial Interest") The ACCME defines an "ineligible company" as those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients. Financial Relationships Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. Relevant Financial Relationships ACCME focuses on collecting information about all financial relationships with ineligible companies within the prior 24 months. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. Individuals must disclose regardless of their view of the relevance of the relationship to the education. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME classifies financial relationships as "relevant" if the educational content an individual can control is related to the business lines or products of the ineligible company. Conflict of Interest Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of an ineligible company with which he/she has a financial relationship. The ACCME considers "content of CME about the products or services of that commercial interest" to include content about specific agents/devices, but not necessarily about the class of agents/devices, and not necessarily content about the whole disease class in which those agents/devices are used.Regarding your role in this CME activity (check one):(Required) No, In the past 24 months, I have not had any financial relationships with an ineligible company. Yes, I do have a personal financial relationship with an ineligible company (Provide information below) Disclosures(Required)To add more, press the (+) button to the right.Nature of Financial RelationshipName of Ineligible Company(s)Has the relationship ended? Add Remove* Community Health Network PROHIBITS employees and owners of ineligible companies from participating on any CME PLANNING COMMITTEE and serving as presenters. Additional information may be requested to address any perceived conflict of interest. All identified conflicts of interest must be mitigated in advance of the activity and disclosure information will be shared with activity participants.Step 2: Speaker Disclosure of Off-Label and/or lnvestigational UsesIf at any time during my educational activity, I discuss an off-label/investigative use of a commercial producUdevice, I understand that I must provide disclosure of that intent.Speaker Disclosure of Off-Label and/or lnvestigational Uses(Required) No, I do not intend to discuss an off-label/investigative use of a commercial product/device. Yes, I do intend to discuss off-label/investigative use(s) of the following commercial product(s)/device(s). Please enter commercial product(s) / device(s) which you intend to discuss off-label or investigative use(s)(Required) Add RemoveStep 3: COMMUNITY HEALTH NETWORK Statements & Rules to Ensure Content ValidationWe would like to enlist your help to ensure that educational content is fair and balanced and that any clinical content presented supports safe, effective patient care. This includes the expectations that: 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. Citations of the work are recommended. The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific business interest of a commercial interest. Recommendations involving diagnosis and treatment discussed in the presentation are based on evidence which is accepted within the profession of medicine as adequate justification for their indications and contraindication in the care of a patient. 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 the accredited provider 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. Content cannot be included in accredited education if it advocates for unscientific approaches to diagnosis or therapy, or if the education promotes recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits, or which are known to be ineffective in the treatment of patients. I understand that COMMUNITY HEALTH NETWORK CME staff will need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance, as requested. I understand that commercial entity corporate names or logos should not appear on my slides or handouts. I understand that COMMUNITY HEALTH NETWORK CME staff may be attending the event to ensure that my presentation is educational, and not promotional, in nature. If I am discussing specific health care products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any individual company. If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker's bureau) for any ineligible company, the promotional aspects of the presentation will not be included in any way with this activity. If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods and will not promote the commercial interest of the funding company. If I am presenting research studies, I will include weaknesses and strengths of each study, in addition to harms and benefits of specific products. I will also discuss studies presenting different conclusions about the product, if available. If you have any questions regarding your ability to comply, please contact Jeff Carter, CME Coordinator, at 317-621-3845, or by email at jcarter3@ecommunity.com.Step 4: DeclarationSignature(Required)I will uphold Community Health Network CME standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development or presentation of this continuing education activity. I understand that CME accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).Attestation(Required) By checking this box, I attest that the completed information is accurate.
