GASP ACTIVITY SPEAKER FORM

GASP ACTIVITY SPEAKER FORM back to meetings page

This form is for speakers, currently booked to present at the GASP Annual Meeting.

Attention Speaker: Please take the time to complete the form below in its entirety. The information you submit is critical to our planning, accreditation and outcomes measurement.

Speaker Name *

Email Address *

Required entries with every submission*

CONTACT INFORMATION

Mailing address

Office Phone

Mobile Phone

Home Phone

Fax

Assistant's Name

Assistant's Phone

Assistant's Email Address

Please list how you wish to be listed in the program

BIO (used in the Meeting Program and excerpts taken for verbal introduction)

GAP ANALYSIS

In accordance with ACCME Planning Policies, please identify the following in relation to your presentation topic(s):

Best Practice - A best practice may be from a national guideline or consensus statement from a credible organization, from peer-reviewed medical literature where more than one source agree on the practice, or from the considered opinion of the expert-planner in the case when no published guideline exists. This becomes the end-goal for your presentation(s).

Current Practice - You can determine this based on interviews (formal or informal) with members of the target audience, a questionnaire, or a published article that reports on findings from learners. THE KEY IS TO GO BEYOND EXPERT PERCEPTION OF THE GAP AND TO INCLUDE THE PERCEPTION OF THE LEARNER.

Gap - This resulting gap is based on the difference between best practice and current practice. Indicate the type of gap (please check all that apply):

Learners lacked knowledge (K)

Learners lacked competence (C)

Learners couldn't implement in practice or performance (P)

EDUCATIONAL OBJECTIVES / OUTCOMES MEASUREMENT

The GASP Programming Committee has provided you with basic objectives for the topic(s) that you will be presenting. As an expert in the field however, please expand upon the provided objectives by completing this form. Objectives are not expected to be exhaustive. They should make clear the knowledge, skills or attitudes that will be gained by the participant.

PRESENTATION 1

Title:

Upon completion of this lecture/workshop/panel, the participant should be able to:

Pre-test/Post-test Question - Please submit a multiple-choice question to test attendees' knowledge or competency of each topic pre- and post- presentation. Your question should be straightforward; no trick questions please!

Question 1

Answers - please enter 1 per line
A)
B)
C)
D)
E)

Correct Answer

SKIP AHEAD TO AV Requirements if you are presenting only one topic.

PRESENTATION 2

Title:

Upon completion of this lecture/workshop/panel, the participant should be able to:

Question 2

Answers - please enter 1 per line
A)
B)
C)
D)
E)

Correct Answer

PRESENTATION 3

Title:

Upon completion of this lecture/workshop/panel, the participant should be able to:

Question 3

Answers - please enter 1 per line
A)
B)
C)
D)
E)

Correct Answer

In an effort to focus our funding efforts, please assist us by listing companies that might find your topic(s) of interest and might want to support the meeting financially:

AUDIO VISUAL REQUIREMENTS - I will need the following equipment for my presentation(s):

LCD Projector/Wireless Remote/Laser Pointer

Other AV needed:

I require only voice amplification OR my presentation(s) will include sound beyond my oration.

I will be presenting via Microsoft Power Point and have NO integrated video in my presentation(s) (a laptop will be provided)

I will be presenting via Apple Keynote or other software (speaker must provide laptop to run onsite)

I have integrated video into my presentation file (speaker must provide laptop to run onsite)

FINAL PRESENTATION

IMPORTANT: As you are preparing your final presentation(s), in accordance with accreditation requirements, be sure to include a slide stating your financial disclosures, placed just after the title slide.

If you are using Microsoft Power Point and your presentation has NO integrated video, please mail us a copy of your final presentation(s) on CD ahead of the meeting. Allowing the AV technician to have the presentations pre-loaded on our laptop ensures fewer delays and the meeting running on time.

I will mail a CD of my final presentation(s) one week prior to the activity, to GASP - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA 30092

I will email my presentation(s) one week prior to the activity, to mbmcgrail@gasleep.org

HANDOUTS

It is highly encouraged that you supplement your presentation slides with supporting documents, articles, research results, etc. In lieu of passing out printed handouts during the meeting, we will be POSTING PDFs of the presentations and any additionally provided handouts on the GASP website.

YES, I will provide handouts and understand that they will be posted on the GASP website. Please read the following disclaimer and "sign" your name to agree with the statements.

The undersigned Faculty (the “Undersigned”) agrees to:

1. Grant to the GASP a nonexclusive, irrevocable worldwide license to reproduce, make derivative works, publish, distribute, and/or sell the recording, transcript, and/or related materials of my presentation. This license does not prohibit the Undersigned from using this presentation in the future for his/her own professional or personal work.

2. Warrant and represent that, to the best of Undersigned’s knowledge, nothing in the presentation violates the personal rights of others (including, without limitation, any copyright or privacy rights), is factual and contains nothing libelous or otherwise unlawful.

3. Warrant and represent that the presentation is the Undersigned’s own original work, that Undersigned has the authority to enter into this agreement, and the Undersigned is the sole copyright holder or that has attained all necessary licenses from any persons or organizations whose material is included or used in the presentation.

4. Indemnify and hold harmless GASP from any claims for damages, costs or expenses arising from claims of copyright infringement resulting from the publication, sale, dissemination or distribution of any materials submitted and/or presented by the undersigned, either orally or in writing. The undersigned further agrees to indemnify GASP against any liability from any statements, oral or written, made by the Undersigned during or after this presentation.

Entering your name in the following space acts as my signature and agreement to the above statement:

Select one option below:

I will mail a CD of my handouts to GASP - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA 30092.

I will email my handouts to mbmcgrail@gasleep.org

Please acquire a copy of my final presentation from me at the meeting to use as my handout.

NO, I do not authorize my slides or other handouts provided for the activity be posted on the GASP website.

FACULTY DISCLOSURE See Faculty Disclosure Statements

It is the policy of the GASP to comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards for commercial support of CME activities. All faculty are required to disclose to the program audience any real or apparent conflict(s) of interest related to this meeting or its content. Having an interest in or affiliation with the corporate organization does not necessarily prevent you from making the presentation, but the relationship must be made known to the audience. Failure to disclose or false disclosure will require the GASP to identify a replacement for your participation.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for you immediate family as defined above. If an individual is uncertain about what might constitute a potential financial conflict or interest they should err on the side of full disclosure.

Category	Code	Description
Consultant / Advisor	C	Consultant fee, paid advisory boards or fees for attending a meeting (for the past 1 year)
Employee	E	Employed by a commercial entity
Lecture Fees	L	Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial entity (for the past 1 year)
Equity Owner	O	Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial sleep medicine products or commercial sleep medicine services
Patents / Royalty	P	Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant Support	S	Grant support for the past 1 year (all sources) and all sources used for this project if this form is an update for a specific talk or manuscript with no time limitation.

Please select one of the following two options

I DO NOT have any financial relationship to disclose.

I have the following financial relationships to disclose:

Company/Organization:

Code(s): C E L O P S

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation (specify drug(s) or product(s) by name for which the unlabeled use will be discussed.

I have read the Disclosure Requirements and to the best of my knowledge, the information provided on this form is true and correct and represents all items for disclosure. I understand that failure to comply with the disclosure policy, when known and deliberate, may result in disqualification for two years in similar educational or related activities. I agree to promptly notify the program directors is any of this information changes.

Entering your name in the following space acts as my signature and agreement to the above statement:

req.