Posters 2016

All content contributors on a poster must complete this form to finalize submission.


2016 Geriatrics Update - Poster Participants

  • Please upload your most current CV/resume
    *Off-label use is the practice of prescribing pharmaceuticals or devices for an unapproved indication or in an unapproved age group, unapproved dose or unapproved form of administration.
    Select all that apply.
  • If the target audience is not listed above, please list your target audience.
  • Conflict of Interest
  • The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity.

    *Commercial interest, as defined by ACCME, ANCC and ACPE, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients (excepting non-profits, covernment organizations or providers of clinical services directly to patients).

    All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

    **Relevant relationships, as defined by ANCC, ACPE and ACCME are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.

    • Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.
    • Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
    • Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.

  • If yes, please designate below for all actual, potential or perceived conflicts of interest**: (Select all that apply)
  • If a conflict of interest exists, you will be contacted by the course planners to determine how to resolve the conflict.
  • Treatment Recommendations and Research Citations: If you make treatment recommendations or reference scientific research as part of your presentation, please note that all studies and evidence must be referenced on presentation slides or handouts.

    By typing your name or uploading your electronic signature below, you are attesting that all clinical recommendations are based on evidence that is accepted within the profession of medicine and all scientific research referred to, reported, or used in support of or justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection and analysis.

    You are also attesting to the accuracy of the information submitted in this Biographical & Conflict of Interest Form.