Biographical Data Form & Faculty Agreement

Name*

First NameLast Name

Credentials*

Phone Number*

Area CodePhone Number

Email*

example@example.com

If RN, specify Nursing Degree(s):

Please upload your current CV (in .doc or .pdf format)*

Browse Files

Present Employer*

Current Title/Affiliation*

Please include all titles and affiliations you would like listed in the activity announcements

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Position Description*

Educational Background*

	Degree	Institution (Name, City, State)	Major Area of Study	Year Completed
1
2
3
4

Briefly summarize professional experience/expertise related to the topic*

Stating 'see CV' is not acceptable

I hereby represent and warrant that the content of any presentation that I make shall be accurate to the best of my knowledge; shall not violate any copyright, proprietary rights or personal rights of others; and the materials, including photographs, used in the presentation shall not identify, by name or otherwise, suggest the identity of, or present a recognizable likeness of any patient or other individual; or, if they do, I shall have obtained all necessary consents from the subject individual for the further use, distribution and publication of such materials.

I agree to conform to all requirements of the Accreditation Council for Continuing Medical Education (ACCME), American Nurses Credentialing Center (ANCC), Accreditation Council for Pharmacy Education (ACPE) and NKF policies. Should I not comply, I understand that my presentation will be immediately terminated with further action possible. For live activities, I agree to stay within my allotted time frame and not speak off topic. The NKF expects that all individuals involved in NKF provided CME/CE activities adhere to the NKF’s content validation statements.

Content Validation: Specifically, all the recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. If I refer to research that does not meet the generally accepted standards as described above, then I will discuss this during my presentation, and I will disclose that the patient recommendation is anecdotal.

Safeguards against Commercial Bias: The NKF expects that faculty/presenter content and related materials will promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest. We also remind you that CME/CE must be unbiased, scientifically rigorous and include a balanced view of therapeutic options. I will use generic names whenever possible. If my presentation materials include trade names, trade names from several companies will be used where available, not just trade names from a single company.

Educational materials (slides, abstracts, handouts) must not contain any advertising, trade names, or product-group messages.
I will fully disclosure any financial support, proprietary interest, or consultant relationship regarding any product, technique or device to be described in the proposed presentation both on the Disclosure and Biographical Form and from the podium at the time of my presentation.
If my presentation discusses any “off-label” or other non-FDA-approved, investigational use of a medical device or pharmaceutical product, I will disclose that it is not labeled for the use under discussion or that the product is still investigational both on the Disclosure and Attestation Form and from the podium at the time of my presentation.

Please acknowledge your acceptance of the terms identified in this Faculty Agreement by printing/signing your name and dating the form.

Signature*

Note: By signing this application electronically, I certify the information provided is accurate. I understand that an electronic signature has the same effect and can be enforced in the same way as a written signature.

Today's Date*

Date

BIOGRAPHICAL DATA & FACULTY AGREEMENT

Employment Information

Faculty Agreement