Questions are relevant only to the last 12 months.

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* 1. Full name

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* 2. Credentials as you would like them to appear on all AACVPR Annual Meeting marketing materials (example: RN, PhD, FAACVPR, etc.)

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* 3. Please indicate if you accept the invitation to take part in the Beginning Investigator Award presentation. 

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* 4. Do you plan to attend the AACVPR 36th Annual Meeting in person in San Antonio, TX? 

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* 5. Depending upon the travel abilities of the presenters selected for the Beginning Investigator Award, we may switch the session to take place virtually before the conference. If we shift the session to take place virtually, would you still be interested in participating? 

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* 6. Do you have an affiliation with a commercial company that will have an impact on the planning of presentation(s) at this activity?

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* 7. Will your presentation include discussion of any commercial product or services?

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* 8. Do you have a financial interest/arrangement or affiliation that would be considered a conflict of interest?

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* 9. Do you have a financial relationship related to: Grant/Research Support?

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* 10. Do you have a financial relationship related to: Consultant?

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* 11. Do you have a financial relationship related to: Speakers' Bureau?

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* 12. Do you have a financial relationship related to: Major Stock Shareholder?

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* 13. Do you have a financial relationship related to: Other Financial or Material Support?

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* 14. AACVPR 36th Annual Meeting Speaker Agreement

PRESENTER agrees to plan logistics and prepare graphic materials as well as conduct appropriate research, planning, overall program design, and visual aid preparation. Final PowerPoint presentation(s) and any additional visual presentation aids are due to AACVPR for review and approval by AUGUST 9, 2021.

PRESENTER grants AACVPR a non-exclusive, royalty-free, perpetual, worldwide license to distribute copy or otherwise publish presentation material to AACVPR membership or general public at the time of, and immediately after, the presentation date. “Presentation Material” comprises PDF presentation handouts and any video/audio recording. AACVPR’s publication or distribution of presentation material may be in any form, whether print/hard copy, electronic, via posting on the AACVPR website or any other form know known or hereafter developed. Publication or distribution may be subject to a fee charged by AACVPR.

It is agreed AACVPR will not be held responsible for royalties or damages resulting from intellectual property infringement from 1) AACVPR’s use and/or distribution of presentation materials in a manner consistent with this agreement or 2) any use or misuse by any person who directly or indirectly obtains the presentation materials as a result of AACVPR’s permitted use and/or distribution rights outlined in this agreement.

Presenter acknowledges understanding that if the event is cancelled due to an act of God (i.e., fire, flood, curtailment of all transportation services, civil unrest, etc.), there will be no obligation to AACVPR or the presenter, except for the expenses already incurred by the presenter. The presenter acknowledges understanding that should the event be postponed due to an act of God (i.e., fire, flood, curtailment of all transportation services, civil unrest, etc.), there will be no obligation on the part of AACVPR or the presenter unless the event is able to be rescheduled.

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* 15. Please indicate your understanding of and willingness to comply with each statement below.
  • I have disclosed all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.
  • 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 proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.
  • I understand that the AACVPR may need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.
  • If I am presenting at a live event, I understand that a monitor will be attending the event to ensure that my presentation is educational, and not promotional, in nature.
  • If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.
  • 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, discuss pros and cons, and not use just trade names from any single company.
  • If I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA for labeling or advertising.
  • If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.
  • As a presenter of an educational session at AACVPR’s 2021 Annual Meeting, I represent that I own all copyrights to the material in my presentation, or I will obtain written permission for myself and AACVPR to use, reprint and distribute to use and reprint copyrighted material from the copyright holder. I will include all written permissions I receive from others on the materials I submit for this educational session. My selection below indicates that I agree to assume complete responsibility for meeting all applicable copyright laws regarding my presentation
Your signature on the form indicates your agreement to follow the policy, and disclosure of affiliations you have with companies that can have an impact on your planning and/or presentation. A signed Conflict of Interest/Disclosure Declaration form is required for all category 1 programs. I have read the Conflict of Interest/Disclosure Declaration Statement information and agree to abide by this policy. By typing your full legal name and date, you are submitting an electronic version of your signature. Type your full name and date (i.e. Jane Doe 5/15/21).

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