APIC MN Fall Conference Speaker Form

  Identification of Infectious Disease Processes
  Surveillance and Epidemiologic Investigation
  Preventing/Controlling the Transmission of Infectious Agents
  Employee/Occupational Health
  Management and Communication
  Education and Research
  Environment of Care
  Cleaning, Sterilization, Disinfection, Asepsis
  Breakfast
  Lunch

Commercial Support is defined as financial or in-kind contributions given by a commercial interest, which is used to pay all or part of the cost of the educational activity. All presenters and planning partners for APIC Minnesota (APIC MN) activities must disclose any financial relationships with commercial interest(s). These include relationships that have occurred within the last 12 months, related to the content of the activity or providing grant support to the activity, including financial interest for spouses/partners.

At the beginning of each of their presentations, presenters are required to verbally disclose any financial relationship(s) information to the learners. Presenters are also required to display a slide at the beginning of their presentation(s) containing disclosure information. If there are no financial relationships to disclose, you are required to indicate ‘nothing to disclose.’

The intent of the disclosure(s) is to provide attendees, prior to the beginning of the learning activity, with information on which they can make their own independent judgments pertaining to program content. APIC MN will review and identify potential conflicts of interest, and resolve all conflicts of interest prior to your participation in the learning activity. Conflicts of interest may occur when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of learning activity about the products or services of that commercial interest. Presenters who fail to provide adequate disclosure, consistent with this policy, will be prohibited from participation as presenters or planners in any APIC MN educational activities.

  I have read and AGREE to the terms of conditions of the APIC MN Conflict of Interest Disclosure of Financial Relationships Agreement.
  I have read and DO NOT AGREE to the terms of conditions of the APIC MN Conflict of Interest Disclosure of Financial Relationships Agreement.
  I am declining honorarium for this presentation.

All Continuing Education Activity Contributors must complete this form
I, (Your Name) certify the following:

· I have participated sufficiently in the work to take public responsibility for the content of the presentation and have given final approval of the version to be presented.

· My presentation represents valid work and that my presentation does not, in whole or in part, copy or otherwise infringe upon the copyright or other proprietary right of another party.

·  I have obtained, and will deliver if requested, written authorization to disclose any identifiable or potentially identifiable private health information of patients discussed in my presentation.

· I hereby grant APIC MN permission to video and/or audio record my presentation for future use and post handouts on the APIC MN website with appropriate faculty acknowledgement.

·  If applicable: I understand that my presentation will be distributed over the Internet using streaming media technology.

For APIC MN Copyrighted Material:

· I will not, at any time or for any purpose, make use of, disseminate, or reproduce any APIC MN copyrighted material without the express written consent of APIC MN.