1. Poster Title:

2. Presenter Information: All authors must complete and submit this form online.

Are you the Primary Presenter? Yes    No

Are you an AMDA member? Yes    No

Are you a CMD? Yes    No

Site of Service Please indicate which site of service along the LTC continuum that your presentation will address:

3. Abstract: You may cut and paste your abstract here.

4. Background Description (Must include information that is particularly relevant to the topic of your presentation)

Education/degrees/certification

Professional position(s) and accomplishments related to topic to be presented (e.g., special preparation, formal or informal job duties)

Presentation at professional conferences related to topic to be presented

Publications related to topic to be presented

My signature below indicates that I agree to abide by the decision of the Program Committee as final.

Signature (enter your initials)    Date (mm/dd/yy)

Part III: Faculty Disclosure 

Faculty Disclosure Declaration Policy
In order to ensure the continued success and reputation for integrity of our education programs, the Florida Medical Directors Association (FMDA) has adopted this full disclosure policy. 

It is not only proper, but likely, that faculty will have relationships with industry and corporations. This involvement in many instances brings recognition and prestige to the institution. Support from industry can contribute significantly to the quality of continuing medical education (CME) activities. There is nothing inherently improper in the involvement of commercial support for a CME activity. On occasion, situations may arise in which an individual faculty member has an outside interest that could be perceived as a conflict of interest. There is no attempt to preclude any faculty member from participating in any continuing medical education activity. It is our responsibility to disclose to the participants in that activity the nature of the faculty relationship so those listeners may form their own judgments about the presentation.

With the increased involvement of industry in continuing medical education, several organizations have issued statements and taken positions regarding the proper behavior of both individuals and organizations regarding involvement in commercially-supported CME. The American Medical Association has issued a statement regarding Gifts to Physicians from Industry; the Accreditation Council for Continuing Medical Education has issued Standards for Commercial Support of Continuing Medical Education; The Pharmaceutical Manufacturers Association has published the Code of Pharmaceutical Marketing Practices; and The Code of Interactions with Healthcare Professional; and the Association of American Medical Colleges has adopted Guidelines for Faculty Involvement in Commercially Supported Continuing Medical Education. The FMDA Board of Directors and Education Committee agree with the principles expressed in these documents.

Duty to Disclose

Each faculty member shall disclose any real or perceived relationships that are pertinent to the subject matter and could potentially be interpreted as biasing a presentation. In addition, faculty must disclose "off-label " uses of substances or products included in the presentation that are not approved in the United States and/or the status of substances or products that are being investigated for such use. 
Relationships that must be disclosed include, but are not limited to:

• Service as a paid or non-paid consultant or employee; 
• Significant personal holdings (by the faculty member and/or his/her immediate family) in any commercial entity that provides financial support for this CME activity, or products or services related to the subject matter of the CME activity; 
• Receipt of financial support from a commercial firm or other source (consultant, research, educational grant, speakers bureau, honoraria, royalties, commissions, etc.); 
• Research or institutional support. 

Faculty Disclosure Statement

ALL authors must complete and submit either Section A online, or if Section B is required, the entire Faculty Disclosure Statement form must be downloaded, completed and submitted, it its entirety. 

It is the policy of the Florida Medical Directors Association (FMDA) to ensure balance, independence, objectivity, and scientific rigor in all of its sponsored educational programs. All faculty members participating in these activities are required to disclose any significant financial interest or other relationship(s) that may have a direct bearing on the subject matter. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter. (Significant financial interest or other relationships can include such things as grants or research support, employee, consultant, major stockholder, member of speakers bureau, etc.) The intent of this policy is not to prevent a speaker with a significant financial or other relationship from participating. Rather, it is intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It remains for the audience to determine whether outside interests may reflect a possible bias in either the exposition or the conclusion(s) presented. Participant agrees to accept no payment for participation in this poster activity from any source.

This form must be completed and returned by each presenter/co-presenter.

Activity Title: FMDA’s 2008 ANNUAL Program

Date: Oct. 23-266, 2008

1. Poster Title:

2. Presenter Name 

Please complete and sign Sections A and C, or Sections B and C, below:

SECTION A

I have no financial conflict of interest or other relationship with a commercial entity in relation to this presentation. My presentation does not include discussion of "off-label" substance(s)/product(s) not approved in the United States for use under discussion or of substance(s)/product(s) that are being investigated for such use.

Signature (enter your initials)    Date (mm/dd/yy)

SECTION B: Financial and Scientific Disclosures

In order to maintain scientific balance and integrity in presentations, all disclosures will be included in on-site program materials.

If your response to this section is: Yes, I have a financial interest/arrangement/or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Please complete the March 2005 AMDA/FMDA Faculty Disclosure Statement, which is available by clicking here and submit it separately.

SECTION C: Scientific Integrity and Commercial Support

By signature at the end of this disclosure declaration, I attest that I have carefully complied with ACCME Standards for Commercial Support and FMDA's policies regarding content and presentation of educational material, specifically, that my presentation will (please check each item delineated below to indicate your agreement):

Signature (enter your initials)    Date (mm/dd/yy)