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Speaker Information Form

SOCIETY OF GASTROENTEROLOGY NURSES
AND ASSOCIATES, INC.
401 North Michigan Avenue
Chicago, IL 60611
800/245-SGNA or 312/321-5165

Instructions: Use this format to provide the documentation of an individual's expertise related to his/her role in this activity.

SGNA 35th Annual Course
May 16-21, 2008
Salt Lake City, UT

Biographical Data

* = required

Contact Information
* First Name
Middle Name
* Last Name
Credential
Preferred address
* Home Work
* Address1
Address2
* City
* State
* Country
* Zip
* Telephone    
Fax    
* Email

* Social Security Number or FEIN
(required to process honorarium
Present Position
* Employer
Title
Description

Education: Include basic preparation through highest degree held.

Degree Institution
Name, City, State
Major Area of Study Year Degree Awarded

Use the space below to briefly describe your professional experience or areas of expertise (including publications) related to your involvement in this activity.

THIS INFORMATION WILL BE PROVIDED TO THE SESSION MODERATOR FOR USE AS YOUR INTRODUCTION, so you may wish to write it in the third person.


*

Audio-Visual Equipment Request

*Session Name
Equipment Information:
(If there are multiple presenters in a single session, please coordinate A/V needs and submit one form for the session.)
 
NOTE: If you plan to use computer-controlled slides (e.g., PowerPoint, Freelance Graphics), due to licensing restrictions YOU must provide your own computer and software. SGNA will provide the projector and cables. Upon arriving at the course, please proceed to the Speaker Ready Room to have AV technicians ensure that your computer is configured for use with the LCD projectors provided.
 
Please check which of the following you will need:

Podium microphone and lapel microphone only
Projector for computer-controlled slides/LCD and PROJECTION SCREEN and electric pointer
Internet Connection
VCR & projector for VHS video
Sound from computer to audio system in room
Notes:

Releases

Copyright Release

As a presenter of an educational session at SGNA's 2008 Annual Course, I represent that I own all copyrights to the material in my presentation, or I will obtain written permission to use and reprint copyrighted material from the copyright holder. I will include all written permissions I receive from others on the syllabus materials I submit for this educational session. My signature below indicates that I agree to assume complete responsibility for meeting all applicable copyright law laws regarding my presentation.

* Signature
* Date Signed
* Title of Presentation
Presentation Release

Throughout the year SGNA reviews Annual Course presentations to be used as possible on-line modules. Offering on-line education is a great way to increase the knowledge of SGNA members unable to attend the course, as well as the larger Gastroenterology and endoscopy community. These on-line modules have replaced the audio and video modules that were previously available after each Annual Course.

RELEASE STATEMENT

As a presenter at SGNA's 2008 Annual Course, I give SGNA permission to use my presentation, as well as any complimentary materials, and to make copies available on-line for purchase to SGNA members and associates of this organization after the conference. There are no time restrictions for this sale permission and I understand I will receive no royalties.

* Signature
* Date Signed
* Title of Presentation
Faculty Vested Interest Disclosure Declaration

It is the policy of the Society of Gastroenterology Nurses and Associates, Inc. (SGNA) that all faculty participating in any SGNA-sponsored educational program must disclose any actual, potential or perceived conflicts of interest that may have a direct bearing on the subject matter being presented.

Such conflict may include, but not be limited to:

  1. Any impropriety or perceived impropriety between the official activities of SGNA and paid or unpaid activities for other professional organizations or for-profit companies
  2. Any member who is an owner, employee, consultant, stock or bondholder, lecturer, officer or director for any health-related manufacturer, distributor or licensee of products or services associated with gastroenterology, endoscopy or patient care.

It is not the intent of this policy to prevent a speaker with potential conflicts of interest from making a presentation. However, it is imperative that these relationships be explicitly disclosed during the presentation so that participants may form their own judgments about the presentations.

SGNA PROGRAM: 2008 ANNUAL COURSE

I, the undersigned, declare that I have no actual, potential or perceived conflicts of interest in relation to this program.

- OR -

I, the undersigned, declare that I have an interest/arrangement or affiliation with an organization(s) that could be perceived as a real or apparent conflict of interest. This fact will be noted in the Course syllabus. Such disclosure allows the audience to better evaluate the objectivity of the information presented in sessions.

Organization:
Organization:
Organization:

* Signature
* Date Signed
* Title of Presentation

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401 North Michigan Avenue - Chicago, IL 60611-4267
P: 800/245-7462, in Illinois: 312/321-5165 - F: 312/673-6694