2017 AACPDM Fred P. Sage
Award Submission
Submission deadline: March 17, 2017
Information /Guidelines
A multimedia submission is an audio/visual presentation that displays clinical, research or educational materials on video via a web-based project (such as a YouTube video), or as an app for devices such as a smart phone. If your multimedia presentation is selected as the winner of the Fred P. Sage Award, we will post on the AACPDM website the title, a brief submission and contact information to those who are interested in contacting you about your multimedia presentation. We will also ask your permission to post a direct link to all or a trailer (short clip) of your multimedia presentation on the AACPDM web site. This will provide improved access to these valuable teaching tools beyond the time of the meeting to the AACPDM membership. PERMISSION TO POST ALL OR PART OF YOUR MULTIMEDIA PRESENTATION IS NOT A CONDITION OF SUBMISSION AND ACCEPTANCE.
Submissions for the Fred P. Sage Award are reviewed by the AACPDM Communications Committee. Submissions are judged on quality, clarity, effectiveness as a teaching tool for a specified audience, and use of media. Dr. Sage envisioned the great potential of audio-visual use in AACPDM. He advocated for ways to popularize this method of teaching, and his interest lead to the Fred P. Sage Award for Best Multimedia Submission. The winner of this award will receive $500 USD and will be asked to present up to five minutes of the winning submission during the AACPDM Annual Meeting.
A complete Multimedia Submission includes the following:
- A completed multimedia application form, including biological data, disclosure, and limited license forms. Please note: disclosure and limited license information is required from every author listed on a presentation. Authors submitting submissions to AACPDM must disclose any potential conflicts of interest and financial relations with industry.
- An electronic copy of the original submission, including title, authors’ names, primary author’s address, full text (250 words or less) and acknowledgements, emailed to
- Copy of your institution’s media release form used for the submitted multimedia presentation.
If accepted for the final program at the annual meeting, we will also request if you agree to have full access of your multimedia presentation with the following:
- Written permission to post a link to access your submission via a web site, or to post a clip of your submission with contact information on AACPDM website.
Please forward the completed submissions to:
Deadline for submission of a 2017 Multimedia Submission is March 17, 2017. Submissions will only be accepted by email. The winner of the Fred P. Sage Award will be notified in May 2017.
Submission Title: ______
______
Corresponding Author:
______
Name Academic degree/title
______
AddressCity, state, zip code
______
Phone #Email Address
Presenting Author: Name, Academic degree/title, Institution:
______
Co-author(s): Name, Academic degree/title, Institution:
1. ______
2. ______
3. ______
All communication will be sent to the person named as the Corresponding Author. He/she will serve as the communication link between the AACPDM and the author(s).
Purpose of this Multimedia Presentation:
To produce a change in attitude (A)
To provide general information (I)
To present highly factual information (F)
555 E. Wells Street, Suite 1100 ● Milwaukee, WI ● Phone (414) 918-3014 ●
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2017 AACPDM Fred P. Sage
Award Submission
Submission deadline: March 17, 2017
Target Audience of this Multimedia Presentation:
Individuals with disabilities/family of individuals with disabilities (I)
Professionals (P)
General Public (G)
Availability of this Multimedia Presentation:
Rental (R)
Purchase (P)
Free/Loan (F)
555 E. Wells Street, Suite 1100 ● Milwaukee, WI ● Phone (414) 918-3014 ●
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2017 AACPDM Fred P. Sage
Award Submission
Submission deadline: March 17, 2017
Length of presentation in minutes: ______
Access via website:
Will give permission to provide a link to my presentation on AACPDM web site
Will provide short clip and contact information for my submission to be posted on AACPDM web site
Decline to give permission (does not affect acceptance of presentation or consideration of Sage award)
Do not know at this time
The appropriate ethical review committee has approved research involving human subjects or animals:
YES NO
Check one:
Commercial Non-commercial
555 E. Wells Street, Suite 1100 ● Milwaukee, WI ● Phone (414) 918-3014 ●
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2017 AACPDM Fred P. Sage
Award Submission
Submission deadline: March 17, 2017
Corresponding Author:
______
SignatureDate:
______
Print name:
Author Biological Data For Evidence Statements
Please provide documentation of an individual’s expertise as required by an evidence statement
(Do not attach any additional materials): Presenter Moderator Other, please specify:
Full Name (including degree/title):
______
Employer/ Present Position: ______
Description of Position:______
Address (number and street):______
City/state :______Zip/Postal: Code:______
Telephone:______Email:______
Education
Include basic preparation through highest degree held in the following order: Degree, institution name & location, major area of study, year degree awarded.
______
______
______
Use the space below to briefly describe your professional experience or areas of expertise (including publications) related to your involvement in continuing medical education and your particular role, e.g., planner, presenter, peer reviewer, administrator, etc. Attach another sheet as necessary. DO NOT INCLUDE CVs.
______
______
______
2017 Annual Meeting Financial Disclosure Form
555 E. Wells Street, Suite 1100 ● Milwaukee, WI ● Phone (414) 918-3014 ●
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2017 AACPDM Fred P. Sage
Award Submission
Submission deadline: March 17, 2017
Please read the following statements and place a check in the box of the statement that applies. If you have received something of value from a commercial company or institution that relates directly or indirectly to the subject of your multimedia presentation, place a check in the box that applies and include the name of the commercial company or institution that provides the support.
The AACPDM does take disclosure information into consideration when accepting multimedia submissions, but the existence of these interests or commitments does not necessarily imply bias or decrease the value of your participation.
□ I or a member of my immediate family have received something of value* from or own stock (or stock options) in a commercial company or institution related directly or indirectly to the subject of my presentation. *Any item, payment, or service valued in excess of $500
Check all that apply:
a. Research or institutional support has been received.
b. Miscellaneous non-income support (e.g., equipment or services), commercially derived honoraria, or other non-research related funding (e.g., paid travel) has been received.
c. Royalties have been received.
d. Stock or stock options held.
e. Consultant or employee.
Please name the source(s) for any of the items selected above:
______
□ I or a member of my immediate family have not received anything of value* from or own stock (or stock options) in a commercial company or institution related directly or indirectly to the subject of my presentation. *Any item, payment, or service valued in excess of $500.
Signed: ______Date: ______
Print Name: ______
Limited License Release Form
PERMISSION TO COPY
Copies of Multimedia submissions and DVDs are sent to each member of the Communications Committee for grading and review. After the review process, the copies in the procession of committee members will be destroyed. Submission will not be returned to authors.
The AACPDM office reserves the right to request and make extra copies of each Multimedia Submission as necessary for evaluation in the course of selecting the winner of the Fred P. Sage Award.
By signing below you give AACPDM the permission to copy and retain copies of your full multimedia submission.
Submission Title: ______
Institution/Publisher:
______
Corresponding Author:
______
SignatureDate
______
Print name:
Co-author(s):
______
SignatureDate
______
Print name:
______
SignatureDate
______
Print name:
______
SignatureDate
______
Print name:
555 E. Wells Street, Suite 1100 ● Milwaukee, WI ● Phone (414) 918-3014 ●
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