Western Psychiatric Institute And Clinic

Industry-Sponsored Presentations/Events

Per policy HS-AD0825, attendance of WPIC faculty, staff or trainees at industry-sponsored meetings (as either an attendee or as a speaker) is subject to the following restrictions:

Ø The event or activity is evidence-based and the financial support of industry is prominently disclosed.

Ø Attendees do not receive gifts or other compensation for attendance including travel expense.

Ø Meals provided are modest and consistent with the educational or scientific purpose of the event.

If a WPIC representative intends to participate as a speaker in an industry-sponsored event, this form must be completed and submitted for approval. All industry-sponsored talks and activities (formal presentation, informal discussion, disease state talks, etc.) must be approved by the Chairman or his designee prior to the event.

For an event to be approved, all of the following criteria must be met:

[ ] The completed request form must be received at least 4 weeks in advance of the presentation.

[ ] An electronic copy of the slide presentation must be submitted for content review if applicable.

[ ] All content must be determined by the speaker and reflect a balanced assessment of the current science and treatment options.

[ ] No promotional slides or materials supplied by pharmaceutical companies are permitted.

[ ] No internal (unpublished) data from pharmaceutical companies are permitted.

[ ] Safety and efficacy data must be peer-reviewed with appropriate citations listed.

[ ] The speaker must state that the views expressed are the views of the speaker and not WPIC.

[ ] Compensation for this event is limited to an honorarium not to exceed $2,500 and reasonable reimbursement of travel expenses.

[ ] No faculty or staff member is permitted to receive remuneration for on-site talks.

WPIC Presenter: Printed Name/Signature: /

WPIC Presenter Contact Info: Phone # Fax #

Date of Request:

Date/Time of Presentation:

Location:

Pharmaceutical Company:

Contact number:

Subject/title and description of presentation and target audience:

I have reviewed the material to be presented and find it to be free from commercial bias.

I approve/do not approve the presentation:

David J. Kupfer, MD or Ken Nash MD (designee)/Date

Comments:

Please return this completed form to E-724 WPIC or via fax to 412-246-6826 for review.

An approved copy will be returned to the WPIC representative making the request. Thank you.

Received: Returned to WPIC representative: