Speaker Information
You must have a disclosure slide included in your presentation. If you don’t have one, click this link for some examples. CME Disclosure Slides (). If you have any questions, please contact your planner.

Presenters should refrain from using A/V materials for which they do not have copyright or permission for usefrom the copyright holder. This includes songs, video, still images, graphics, tables, or other materials which are understood not to be in the public domain.

Your Demographic Information
  1. our name and credentials: (Please complete your demographic information as you would like to see it in print)

  1. Your title and organizationname; title, department, and specialty

  1. Organization address, including city, state, and zip.

  1. Your phone number, fax number and email address

  1. What is the best way to contact you?
/ Phone______
Email______
  1. Name and contact information of assistant:

  1. Name of the CME activity at which you are presenting:

  1. Date of your presentation:

  1. Presentation title (as you would like to see it in print):

Specifics Related to Your Topic
Please give us two to four learning objectives for your attendees (For tips on writing learning objectives click here.
  1. “As a result of participating in this activity, the participant will be able to……”

  1. All continuing medical education must contribute to physician competency. The following is a list of ABMS/ACGME Physician Competencies. Please check those that would be addressed in this activity.
/ Patient care
Medical Knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
Systems-Based Practice
  1. The following is a list of Institute of Medicine (IOM) Competencies. Please check those that would be addressed in this activity.
/ Provide Patient-centered Care
work in Interdisciplinary Teams
Employ Evidence-based Practice
Apply Quality Improvement
Utilize Informatics
  1. What educational format will you use?
/ Lecture/Presentation
Panel discussion
Group discussion
Case Presentation
Problem solving
Other. Describe:
Measuring Outcomes
Referencing your Learning Objectives above, please provide us with one to two case based scenarios which we can use with participants to demonstrate their mastery of your topic: (In those few situations where a case scenario simply does not apply, please substitute with a Q&A). (For tips on writing case scenario question click here.
  1. Case description (includes a question at the end for the participant to answer):

Multiple Choices:
(use as many as you wish)
Correct Answer
  1. Case description (includes a question at the end for the participant to answer):

Multiple Choices:
Correct Answer
Your Audiovisual and Technology Needs:
We will provide:
  • a computer with PowerPoint and Windows Media
  • screen
  • microphone
  • laser pointer/advancer combination to remotely advance your PowerPoint
  • podium
  • LCD to project your PowerPoint

  1. What other equipment or audiovisual support will you need?
/ DVD player
Audience Response System (Clickers)/Poll everywhere $$
Audience Microphone
I will need internet access
I will bring my own Mac
I will bring/provide a DVD/Video Clip
Other______
  1. Would you like for us to contact you regarding your technology needs?
/ Yes No
Conflict of Interest Disclosure & Mutual Accountabilities
Please click on the link (or copy and paste URL ) to complete the disclosure and accountabilities requirements.
This disclosure must be made at least once every 12 months, or more often if relationships with commercial interests have changed at the time of planning/presenting at an educational event.
This form provides you with the opportunity to submit your disclosure information and other documentation needed by the Quillen College of Medicine Office of CME for planners and presenters, in accordance with the requirements of the ACCME, ANCC, and ACPE.
Permissions:
Do we have your permission to
  1. I give CME permission to record and/or to send a live broadcast of the presentation identified above. I agree to allow CME to use this recording for education and other related purposes.Please note, this recording will be used on our website for up to two(2) years, unless otherwise specified.
/ Yes
No
  1. Use the handout from your PowerPoint…
    (Please indicate your choice)
/ Yes No
CMEwillemail presentations to registered attendees prior toevent.
Other uses or limitations:

Please save this document for your files and return an attached copy via email to Karen Mabe.
We will notify you that we have received this document. Thank you for your time and your commitment. Please call us at 423-439-8081 if you have any questions.

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