National Grand Rounds SUBMISSION

AAPM&R National Grand Rounds (NGR)

Proposal Submission Form
Lead Presenter's Information
Name

First NameLast NameCredentials
Lead Presenter's Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
AAPM&R Member ID (if known)
Years in Practice
FINANCIAL DISCLOSURE

This form must be completed even if you have no financial relationships with ineligible companies to disclose. Failure or refusal to disclose financial relationships will result in disqualification from participating in the activity. Your information will be disclosed to all participants prior to the start of this activity.
In the past 24 months, have you (or an immediate family member) had a financial relationship with a commercial organization that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients?
If you have financial relationships to disclose, complete the table below.
FDA DISCLOSURE

Faculty members are also required to disclose the FDA clearance status of pharmaceuticals and medical devices discussed in any educational activity. Please make the appropriate selections below
Please make the appropriate selection below.
Please, complete the table below.
Will additional speakers be joining you?
Additional Presenters

Please provide the names and email addresses of all additional presenters. By submitting this information, you acknowledge that automated emails will be sent to request disclosure forms and that your submission will remain pending until all disclosures are received.
Co-Presenter #1 Name
Co-Presenter #1 Email
example@example.com
Co-Presenter #2 Name
Co-Presenter #2 Email
example@example.com
Co-Presenter #3 Name
Co-Presenter #3 Email
example@example.com

Session Information
Proposed Session Title:
Provide a brief description of your session proposal:
Why is this session needed? Details should include the knowledge or practice gap the session is intended to fill.
List 3-5 learning objectives that are clear, measurable, and achievable. Use actions words such as list, describe, define, demonstrate, conduct, etc. Complete the sentence, "As a result of attending this session, participant will be able to..."
Please describe the speaker(s)’ expertise and experience related to the proposed topic.
Please Sign Here
Hidden Information
Submission Complete Email
example@example.com
Count Co-Presenter One
Count Co-Presenter Two
Count Co-Presenter Three
Total Number of Co-Presenters

AAPM&R National Grand Rounds (NGR)

Co-Presenter Disclosure Form
Co-Presenter One
Name

First NameLast NameCredentials
Proposed Session Title:
FINANCIAL DISCLOSURE

This form must be completed even if you have no financial relationships with ineligible companies to disclose. Failure or refusal to disclose financial relationships will result in disqualification from participating in the activity. Your information will be disclosed to all participants prior to the start of this activity.
In the past 24 months, have you (or an immediate family member) had a financial relationship with a commercial organization that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients?
If you have financial relationships to disclose, complete the table below.
FDA DISCLOSURE

Faculty members are also required to disclose the FDA clearance status of pharmaceuticals and medical devices discussed in any educational activity. Please make the appropriate selections below
Please make the appropriate selection below.
Please, complete the table below.
Please Sign Here

AAPM&R National Grand Rounds (NGR)

Co-Presenter Disclosure Form
Co-Presenter Two
Name

First NameLast NameCredentials
Proposed Session Title:
FINANCIAL DISCLOSURE

This form must be completed even if you have no financial relationships with ineligible companies to disclose. Failure or refusal to disclose financial relationships will result in disqualification from participating in the activity. Your information will be disclosed to all participants prior to the start of this activity.
In the past 24 months, have you (or an immediate family member) had a financial relationship with a commercial organization that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients?
If you have financial relationships to disclose, complete the table below.
FDA DISCLOSURE

Faculty members are also required to disclose the FDA clearance status of pharmaceuticals and medical devices discussed in any educational activity. Please make the appropriate selections below
Please make the appropriate selection below.
Please, complete the table below.
Please Sign Here

AAPM&R National Grand Rounds (NGR)

Co-Presenter Disclosure Form
Co-Presenter Three
Name

First NameLast NameCredentials
Proposed Session Title:
FINANCIAL DISCLOSURE

This form must be completed even if you have no financial relationships with ineligible companies to disclose. Failure or refusal to disclose financial relationships will result in disqualification from participating in the activity. Your information will be disclosed to all participants prior to the start of this activity.
In the past 24 months, have you (or an immediate family member) had a financial relationship with a commercial organization that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients?
If you have financial relationships to disclose, complete the table below.
FDA DISCLOSURE

Faculty members are also required to disclose the FDA clearance status of pharmaceuticals and medical devices discussed in any educational activity. Please make the appropriate selections below
Please make the appropriate selection below.
Please, complete the table below.
Please Sign Here
Should be Empty:

AAPM&R National Grand Rounds (NGR)

Lead Presenter's Information

Session Information

Hidden Information

AAPM&R National Grand Rounds (NGR)

Co-Presenter One

AAPM&R National Grand Rounds (NGR)

Co-Presenter Two

AAPM&R National Grand Rounds (NGR)

Co-Presenter Three