SFNS CONTINUING MEDICAL EDUCATION ATTESTATION FORMFor Speakers, Moderators, and Introducers

SPEAKER: COURSE TITLE:

Please indicate your understanding of and willingness to comply with each statement below. If you have any questions regarding your ability to comply, please contact the Excutive Director as soon as possible for clarification.

Amanda Pacia, Executive Director Phone: 650-288-5339 Fax: 650-347-4975 E-mail: apacia@sfneurological.org

Agree Disagree

I verify that prior to the presentation I have requested and/or obtained permission from copyright holder(s) to reproduce/copy, from their work, the portions of my presentation that are protected by copyright laws. I acknowledge that the SFNS will not be held legally responsible for any misrepresentation on my part regarding copyright infringement.

If presenting specific patient cases or case histories, I warrant that I have HIPAA compliant authorization for any PHI (Protected Health Information) in the presentation materials or have de-identified all materials.

I have completed the Disclosure Form, providing information to the SFNS regarding all relevant financial relationships, and I will disclose information to learners verbally and in print.

The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.

I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with SFNS or its designees.

I understand that the SFNS or its designees will need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.

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Agree Disagree N/A If I am providing recommendations involving clinical medicine, they will 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 CME in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.

If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.

If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker's bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.

If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.

Speaker Consent Form

SPEAKER: COURSE TITLE:

1. The San Francisco Neurological Society provides educational materials to all attendees. We request that you consent to this process by reading the following statement and signing below.

I hereby consent to the duplication of my presentation and to its inclusion in the course handouts and to its inclusion in any enduring materials maintained in connection with the course in any format or media whatsoever, including CD-ROM and Website. In addition, I certify that for any work that is not my own, which will be included in my presentation materials, I have obtained all necessary approvals and copyright releases.

Yes No

2. Audiotaping / Videotaping / Photography Release

I GIVE MY PERMISSION to record my lecture and/or photograph my session(s). I understand I shall receive no compensation for recording. I further understand that the recording will be used by the SFNS and may be made available to participants for a fee payable to the SFNS. I also understand that photos of my session(s) may be used in marketing and/or on the CME Website.

I DO NOT GIVE PERMISSION to have my presentation recorded.

I DO NOT GIVE PERMISSION to be photographed. page 2 of 3

3. May we include an e-mail address in the lecture summary/syllabus given to attendees in the event they wish to contact you regarding your presentation? Yes No

E-mail address to use:

I have carefully read and considered each item in both forms, and have completed them to the best of my ability.

Signature

Name Date

If sending this completed form electronically, please type your name above and check this box:

By checking this box, I attest that the completed information is accurate. Please accept this as my signature.

MAIL TO: SFNSAmanda Pacia, Executive DirectorSan Francisco Neurological Society1630 S. Delaware Street, #25327San Mateo, CA 94402

Phone: 650-288-5339Fax: 650-347-4975apacia@sfneurological.org

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