Call for Presentations

5th Annual National Rx Drug Abuse Summit

March 28-31, 2016, The Westin Peachtree Plaza, Atlanta, GA

Deadline for submitting a proposal is Friday, September 11, 2015

Date of Submission:

Title of Presentation:

Description of Presentation (Maximum of 150 words)

Which of the following best describes the topic area of your presentation? Check all that apply. (In past years, potential speakers were asked to select one Education Track for their presentations. This year, you may choose from a wider selection of topic areas. Through this process, up to 10 Education Tracks and pre-summit workshops will be identified.)

Prevention

Advocacy

NAS (during pregnancy and post-delivery)

Pharmacy

Law Enforcement: Investigations

Law Enforcement: Community Policing

PDMP

Treatment

Sentencing Trends (including treatment options in incarceration)

Medically Assisted Treatment

Alternative Prescribing Practices for Pain

Clinical

Youth

Drug Trends

Science of Addiction

Third-Party Payers

Issues in the Workplace

Heroin

Marijuana

Have you made this presentation before?Yes ____No ____

If so, where and when:

Primary Presenter

Please complete and sign the “Conflict of Interest Reporting Form” (page 3) and provide the following information:

First Name: Last Name:

Title: Organization:

Address:

City: State: Zip:

Direct Phone: Email:

Continued on Next Page…

Resume of Primary Presenter to be listed in official show program and on website (Maximum of 150 words)

Co-Presenter

Please complete and sign the “Conflict of Interest Report Form” (page 3) and provide the following information:

First Name: Last Name:

Title: Organization:

Address:

City: State: Zip:

Direct Phone: Email:

Resume of Co-Presenter to be listed in official show program and on website (Maximum of 150 words)

For Each Additional Co-Presenter

Please complete and sign the “Conflict of Interest Reporting Form” (page 3) and submit a separate sheet providing the information that was requested above for the Primary Presenter and Co-Presenter.

Please direct all questions and completed presentation proposals by e-mail to:

Cindy Lackey,

Postgraduate Institute for Medicine

CONFLICT OF INTEREST REPORTING FORM

FOR INSTRUCTORS, PLANNERS AND MANAGERS OF CME/CE ACTIVITIES

Because continuing medical, pharmacy and nursing education (CME/CE) activities are conducted in the public interest, it is important to assure the public that education received by physicians and other health professionals through whom patient care decisions are made is conducted with the highest integrity, scientific objectivity and in the absence of bias. A conflict of interest (COI) exists when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME/CE about the product or services of that commercial interest. The Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC) each hold the provider of continuing education responsible for collecting information from its instructors, planners and managers of CME/CE content and resolving those conflicts prior to the commencement of the CME/CE activity. The intent of the COI resolution process is to assure that provider, faculty and planner financial relationships with commercial interests and resultant loyalties do not supersede the public interest in the design and delivery of CME/CE activities for the profession.

Criteria for Disclosure of Conflicts of Interest

Instructors, planners and managers who affect the content of a CME/CE activity are required to disclose to Postgraduate Institute for Medicine (PIM) financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME/CE activity of any amount over the past 12 months ONLY. A commercial interest is defined by the ACCME, ACPE and ANCC as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Relationships with governmental agencies (e.g., the NIH) do not have to be disclosed. In addition, honoraria received from a CME/CE provider for serving as a CME/CE faculty member by you or your spouse/life partner, even though those funds may have been provided through an educational grant from a commercial interest, DO NOT HAVE TO BE DISCLOSED.

In accordance with ACCME, ACPE and ANCC requirements, failure to provide disclosure information in a timely manner will result in your disqualification as a potential instructor, planner or manager in this activity.

Project ID: 11121 LJ 29Name of CME/CE Activity:Rx Drug Summit 2016

Name(s) of Commercial Interest(s) Providing Support for this Activity (to date):none

Name of Discloser:I am a/an: Instructor Planner/Manager Other: ______

Type of Financial Relationship
WITHIN THE PAST 12 MONTHS ONLY / Indicate Applicable Manufacturer(s)/Company
WITHIN THE PAST 12 MONTHS ONLY
Salary / Self Spouse
Royalty[1] / Self Spouse
Receipt of Intellectual Property Rights/Patent Holder1 / Self Spouse
Consulting Fees (e.g., advisory boards) / Self Spouse
Fees for Non-CME/CE Services Received Directly from a Commercial Interest or their Agents[2] (e.g., speakers’ bureaus) / Self Spouse
Contracted Research[3] / Self Spouse
Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds) / Self Spouse
Other / Self Spouse

If you reported relationships in the chart above, will any of these relationships impact your ability to present an unbiased presentation?

Yes No

I have no real or apparent conflicts of interest to report.

I agree to disclose any unlabeled/unapproved uses of drugs or products referenced in my presentation/materials.

Have you completed the National Faculty Education Initiativeonline course sponsored by the Alliance for Continuing Education in the Health Professions, the Society for Academic CME, and the Association of American Medical Colleges?

Yes No

Signature of Reporting IndividualDate of Submission

[1]For Royalty and Patent Holder relationships, include product name along with Manufacturer/Company. Product information will be used only to identify degree of conflict and will NOT be

disclosed to the learners.

[2]An accredited ACCME/ACPE/ANCC provider is NOT an agent for a manufacturer, whereas a company acting for a manufacturer in a promotional activity IS an agent.

[3]Only include research funds received directly from industry; grants to your institution are reportable only when you’re the person or named investigator on the grant.