FADONA Call for Presentations 2011

FADONA CONVENTION CALL FOR PRESENTATIONS 2012

Please complete the following application for educational program proposals
for FADONA’s 2012 Convention “Carrying the Torch of Leadership 2012,”
April 18-21, 2012 in Orlando, FL.

First Name:

Last Name:

Degree:

Title:

Organization:

Address:

City/State/Zip:

Daytime Phone:

Cell Phone:

Fax Number:

E-mail:

Primary Applicant:

Additional Speaker 1:

Additional Speaker 2:

Duration of presentation

30 minutes 60 minutes 90 minutes

Please e-mail CV to icordes@bellsouth.net

Brief Speaker Bio

Title of Program

Session Overview

Provide a 4-5 sentence description of content of the session and how attendee will benefit from attendance.

Educational Course Objectives

Financial relationship disclosure statement
As the accredited provider of continuing education, FADONA must ensure balance, independence, objectivity, and scientific rigor in all of its educational activities. All faculty participating in a FADONA educational activity and all volunteers participating in content development, authorship or review of enduring materials, or on program planning are required to disclose to the FADONA Education Committee or to the Program Planning Committee any financial interest or other relationship with (1) pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation within the past 12 months, including financial or other potentially conflicting relationships of a spouse or partner. The intent of disclosure is not to prevent new ideas coming into the planning process, but to consider conflict of interest and how it may be resolved and reported to learners prior to the education session/activity.

Please complete and sign Parts A, B, and C below.

Part A:
I do not have any relevant financial relationships with any commercial interests.

OR

Commercial Interest¹ (Self)	Nature of Relevant Financial Relationship (Include all that apply within the past 12 months.)		Product(s) made by the company related to topic(s) considered in planning
Commercial Interest¹ (Self)	What I received²	My Role³
Example: Company ‘X’	Honorarium	Speaker/Consultant/Research

My electronic signature below verifies all information above.

Signature Date

Commercial interest refers to relationships with pharmaceutical companies, companies that produce/provide durable medical equipment, medical communications/education companies, or multi-site facilities (e.g., nursing home chains). Ask FADONA for the Glossary of Terms for additional definitions and examples.
What was received: 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.
My Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

Part B: Off-label and Investigational Use

Products to be described and information to be provided as part of the
presentation include substance(s) or products(s) not approved in the United States
for the use under discussion (off-label) and/or are being investigated for such uses:

Yes No

If “yes”, please describe the substance(s) or product(s) to be discussed.

Electronic Signature Date

Part C: Agreement to abide by FADONA requirements for integrity
My electronic signature at the end of this disclosure statement attests that I have carefully complied with FADONA’s standards for commercial support and its policies regarding content and presentation of educational material, specifically, that content to be presented will:

be for scientific and educational purposes only and will not promote a company’s products directly or indirectly;
reflect total control of content by the planning committee;
include no “scripting”, emphasis, or influence on content by a company or its agents;
adhere strictly to principles of the highest quality, scientific integrity, and selection of content;
be free of commercial influence or bias;
use generic names of pharmaceuticals or other medical products and provide balanced views of treatment options;
ensure that the content of slides, reference materials, and handouts in print, electronic, or other media will not enhance the specific proprietary interests of any commercial entity, or include commercial logos; and
ensure delivery of the presentation free of the participation of industry representatives in the session room.

Electronic Signature Date

Please e-mail CV to icordes@bellsouth.net

Thanks you for submitting your session to the FADONA Convention Submissions Review Committee. If your session is selected, speaker will be provided one (1) complimentary conference registration and one (1) complimentary 1-night stay at the conference hotel.

Florida Association Director of Nursing Administration
200 Butler Street, Suite 305, West Palm Beach, FL 33407
(561) 659-2167 * Fax: (561) 659-1291 * www.fadona.org