Neil Medical Group/Principle LTC Educational Workshop

Transcription

1 FULL DISCLOSURE STATEMENT: CONTINUING PROFESSIONAL DEVELOPMENT (CPD) PROGRAM Individuals need to disclose relationships with a commercial interest if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CPD about the products or services of that commercial interest. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relationships of the person involved in the CPD activity should include financial relationships of a spouse or partner. It is the policy of the CPD Program to insure balance, independence, objectivity, and scientific rigor in all its individually or jointly presented CPD programs. Faculty participating in this CPD Program must disclose any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the CPD program. Disclosure pertains to relationships with any pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of your presentation topic. This information will be obtained from all speakers and will be summarized in the program packet. Your presentation must promote improvements or quality in healthcare and be free of commercial bias. The presentation should give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational content includes trade names, available trade names from several companies should be used, not just trade names from a single company. Your presentation should also reference the best available evidence. CPD Program: Neil Medical Group/Principle LTC Educational Workshop Title of Presentation: Bad Bugs No Drugs: The Importance of Antibiotic Stewardship Presenter s Name: Cathy Fuquay, RPH, BCGP, FASCP Title: Consultant Pharmacist Place of Work: Neil Medical Group Phone #: cathyf@neilmedical.com Address: 8519 Haw River Road City: Oak Ridge State: NC Zip: Level of expertise: 30 Years Experience in LTC as Geriatric Consultant Pharmacist Please circle Yes No Are your research activities funded by a commercial organization? If yes, please name: Yes No Are you currently serving as a paid consultant to a commercial organization relevant to your CPD presentation? Yes No In your opinion, do you have significant investments in or any other financial or business relationship with a commercial organization relevant to your presentation? If yes, please name: Yes No Are there any special relationships between you and a commercial organization that may be relevant to your participation in this CPD activity? If yes, please name: Yes No I affirm that no images, data, or findings presented in my lecture(s) has been falsified or misrepresented in terms of treatment outcomes, results or conclusions. Signature 1/30/17 Please return completed form to: Barbara Bainbridge, Northwest Area Health Education Center/Wake Forest School of Medicine 03/2014, 3/2015, 4/2015, 1/2016, 3/2016, 9/2016

2 03/2014, 3/2015, 4/2015, 1/2016, 3/2016, 9/2016 Medical Center Boulevard / Winston Salem, NC fax / / bbainbri@wakehealth.edu

3 FULL DISCLOSURE STATEMENT: CONTINUING PROFESSIONAL DEVELOPMENT (CPD) PROGRAM Individuals need to disclose relationships with a commercial interest if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CPD about the products or services of that commercial interest. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relationships of the person involved in the CPD activity should include financial relationships of a spouse or partner. It is the policy of the CPD Program to insure balance, independence, objectivity, and scientific rigor in all its individually or jointly presented CPD programs. Faculty participating in this CPD Program must disclose any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the CPD program. Disclosure pertains to relationships with any pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of your presentation topic. This information will be obtained from all speakers and will be summarized in the program packet. Your presentation must promote improvements or quality in healthcare and be free of commercial bias. The presentation should give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational content includes trade names, available trade names from several companies should be used, not just trade names from a single company. Your presentation should also reference the best available evidence. CPD Program: The Neil Medical Group/Principle LTC Educational Workshop Title of Presentation: The Mega Rule: Reform of Requirements for Long Term Care Facilities Presenter s Name: Robert Smith, Pharm D, BCGP, BCPS, FASCP Title: Director of Clinical Services Place of Work: Neil Medical Group Phone #: Ext roberts@neilmedical.com Address: 2545 Jetport Road City: Kinston State: NC Zip: Level of expertise: I am a board certified geriatric pharmacist and board certified pharmacotherapy specialist with over twenty years of practice experience, primarily in the long term care arena. Please circle Yes No Are your research activities funded by a commercial organization? If yes, please name: Yes No Are you currently serving as a paid consultant to a commercial organization relevant to your CPD presentation? Yes No In your opinion, do you have significant investments in or any other financial or business relationship with a commercial organization relevant to your presentation? If yes, please name: Yes No Are there any special relationships between you and a commercial organization that may be relevant to your participation in this CPD activity? If yes, please name: Yes No I affirm that no images, data, or findings presented in my lecture(s) has been falsified or misrepresented in terms of treatment outcomes, results or conclusions. Signature Date 2/1/17 Please return completed form to: Barbara Bainbridge, Northwest Area Health Education Center/Wake Forest School of Medicine 03/2014, 3/2015, 4/2015, 1/2016, 3/2016, 9/2016

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