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Application for Royalty Author Program
2.
General information
On behalf of the CSRC, we thank you for your submission of an on-line course. We kindly request you provide the following information.
*
1.
Background information
(Required.)
First name
Last name
Credential(s)
Degree
Institution (Name, city, state)
Major area of study
Job Title
Company/Employer
Street address
Address 2
City/Town
State/Province
Zip/Postal code
Primary phone number
Email
*
2.
Describe your familiarity with the target audience (Respiratory Care Practitioners)
(Required.)
*
3.
Describe your expertise in relation to the topic(s) you wish to present
(Required.)
4.
Three objectives that include behavioral words from this
link
**Note: If viewing the link above on mobile phone, select “back (<)” button to return to Application
Objective 1
Objective 2
Objective 3
*
5.
Declaration of vested interests
Having an interest or a\iliation with an organization does not prevent participation. Past or present, real, or perceived conflict of interest, by having any financial support or gain from a vendor, must be disclosed during presentation. I acknowledge to abide by the criteria.
(Required.)
No, I have no real or perceived conflicts of interests
Yes, I will disclose during presentation
*
6.
FDA Approved Drug and Devices and Assurance Statement
(Required.)
I attest that any conversations pertaining the usage of FDA-approved drugs or devices outside of the approved regulations (known as o\-label use) are clearly explained for learners.
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