CWISummit Presenter Documentation

Chest Wall Injury Society

Presenter Information
The Chest Wall Injury Society Education Committee is grateful for your contribution to the 2020 CWISummit. This is the main educational activity for our society and a key member benefit, so we appreciate your willingness to share your expertise.

It is critical the meeting is accredited (CME-worthy), and as such, your prompt completion of this online form is necessary. We cannot host this meeting without accreditation so we do not take this process lightly. If you are unwilling or unable to complete the documentation on time, please contact SarahAnn ASAP such that she can either assist you or our Education Committee can identify a replacement for the agenda.

This documentation must be submitted by Friday, January 31. This is a firm deadline so please be mindful and complete.

Thank you again for your time and contribution. We are honored by your participation and look forward to seeing you in April!
Name

First NameLast Name
Credentials
Example: MD, MBBS, FACS, PhD, PA-C, etc
Preferred email*
example@example.com
Mobile or WhatsApp

Area CodePhone Number
Name of work institution
Please upload your professional head shot.

Browse Files

Cancelof
Do you have an administrative assistant we should include on subsequent emails?

YesNo
Administrative Assistant Name

First NameLast Name
Administrative Assistant preferred email
example@example.com

Chest Wall Injury Society

Presenter Information - on-site needs
Brief paragraph of how you would like the moderator to introduce you.
Please click the audiovisual tools you would like for your presentation.

Basic presentation package (laptop, projector, laser pointer/slide advancer, screen)Polling systemSound/audio within presentationVideo within presentationWhiteboard/flipchart, markersFloor easelOther
My presentation(s) __________ include the discussion of an off-label use of a commercial product. If so, I agree to inform the learners of such.
Chest Wall Injury Society

Presenter Information - the fun stuff
What’s your favorite car that you’ve owned?
What mobile app do you use most?
What is one of your favorite travel locations you would recommend to others?
What was one of your favorite television shows when you were growing up?
What movie never gets old no matter how many times you’ve seen it?

Chest Wall Injury Society

Disclosure of Relevant Financial Relationships
A conflict of interest exists when personal activities or relationships interfere (or appear to interfere) with a healthcare professional’s objectivity and judgment in doing what is best for their patient(s) or the operations of the Chest Wall Injury Society.

Please disclose all relevant financial relationships for yourself (and spouse/significant other if applicable) for the previous 12 months. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria for promotional speakers’ bureau, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.

Please note: CWIS considers relationships of the person to include financial relationships of a spouse or partner.

CWIS has not set a minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship.
Disclosure

As a reminder, there is no minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship.
Name

First NameLast Name
Do you have any relevant financial relationships to disclose?*

YesNoI am unsure - please contact me to discuss

Does your spouse/significant other have any relevant financial relationships to disclose?*

YesNoI am unsure - please contact me to discuss

Attestation

By electronically signing my name below, I am indicating the above notation is the full and complete disclosure of current relevant financial relationships for myself (and my spouse/significant other, if applicable) and for the previous 12 months.
Comments
Electronic signature

Clear
Today's Date

MonthDayYear
Date
Questions?

If you have any questions, please email CWIS at information@cwisociety.org.
Should be Empty:

	Relationship	Name of entity/entities
Salary
Royalty
Intellectual property rights
Consulting fee
Honorarium payment for promotional speakers' bureau
Ownership interest (e.g. stocks, stock options, other ownership interests, excluding diversified mutual funds)
Other financial benefits (e.g. employment, management position, independent contractor - including contract researcher, consulting, speaking or teaching, membership on advisory committees or review panels, board membership, other activities from which remuneration is received or expected)

	Relationship	Name of entity/entities
Salary
Royalty
Intellectual property rights
Consulting fee
Honorarium payment for promotional speakers' bureau
Ownership interest (e.g. stocks, stock options, other ownership interests, excluding diversified mutual funds)
Other financial benefits (e.g. employment, management position, independent contractor - including contract researcher, consulting, speaking or teaching, membership on advisory committees or review panels, board membership, other activities from which remuneration is received or expected)

Chest Wall Injury Society

Chest Wall Injury Society

Chest Wall Injury Society

Chest Wall Injury Society

Disclosure

Attestation

Questions?