Abstract Submission

Resident Information

Complete the following form to begin the submission process.  If your institution is not listed in the drop down box or has changed, please select "Other" from the dropdown and enter the institutions name in the "Other" text box.  Please try to insure that the institution name is the same for all residents for that location.

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Presentation Questions

1. Completion of a conflict of interest disclosure form:




 

2. Learning objectives:




 

3. Active learning:




 

4. Slide sets:




 

5. Learning assessment questions:




 
 

 

Conflict of Interest Declaration

ACPE Guidelines on Non-Commercialism and Conflict of Interest Declaration

  • All continuing pharmacy education (CPE) activities should provide for an in-depth presentation with fair and full disclosure and equitable balance. Appropriate topics and learning activities shall be distinguished from topics and learning activities which are promotional or appear to be intended for purpose of endorsing either a specific commercial drug or other commercial product (as contrasted with the generic product/entity and its contents or the general therapeutic area it addresses), or a specific commercial service (as contrasted with the general service area and/or the aspects or problems of professional practice it addresses).
  • Commercial interest is defined as any proprietary entity producing health care goods or services, with the exception of non-profit or government organizations and non-health care related companies.
  • Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the CPE educational material or content includes trade names, where available trade names from several companies should be used, not just trade names from a single company.
  • An individual must disclose to learners any relevant financial relationship(s) prior to the beginning of the educational activity.
  • Disclosure should be described in the slide presentation, usually the second slide (if live presentation) or in any handout.
  • For an individual with no relevant financial relationship(s) the learners must be informed that no relevant financial relationship(s) exist.
  • If there is a relevant financial relationship, the conflict must be resolved prior to the activity.
  • Disclosure due to a relationship with a commercial interest is required 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 CPE about the products or services of that commercial interest.
  • Financial relationships are those relationships in which the individual benefits by receiving 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.
  • ACPE considers relationships of the person involved in the CPE activity to include financial relationships of a spouse or partner.
  • All individuals involved in a activity must sign a conflict of interest declaration, including those on a planning committee.
  • Anyone who refuses to sign a conflict of interest declaration may not be involved in the activity.

PART 1: TO BE COMPLETED BY PARTICIPANT (read ACPE guidelines on non-commercialism)


Please give a brief explanation of the conflict

I understand the above information will be disclosed to the audience in advance of the activity verbally (for live activities) and in print. My disclosure provided above is accurate for the past 12 months. All recommendations involving clinical medicine in my presentation are based on evidence that is accepted within the health profession as adequate justification for their indications and contraindications in the care of patients. All scientific research referred in, reported, or used in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, and analysis.

I understand that I must submit activity material (i.e. slides, handout, home study program) at least 4 weeks in advance of the event so that it may be reviewed for conflict of interest/potential bias. By signing this document I have read and agree to all the set requirements and guidelines set forth by the provider.

By submitting this information you are attesting that your statements are true and factual.

Signature     I understand that by typing my name in this box, I am affirming the truth of the above conflict of interest declaration.  This serves as my signature of agreement.

 

Please click "Select" to open a window that will allow you to browse your drives for your CV. Select your CV and click "Open". Verify the correct file was selected then click "Upload".


Abstract Information

Select area of pharmacy practice that is most closely related to your abstract
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Will off label use (i.e. non-FDA approved uses) be discussed during the presentation?
Plese select the ACPE Topic Designator from the drop down box that your presention topic is most related to:
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Title of Research Project  
Author(s) (Include all authors.  Provide first names, middle initials, last names.  Asterisk the name of the author presenting.  Include degree designations)
Abstract (limit to 300 words or approximately 2200 characters)  
Learning Objectives - Select a verb from the dropdown box and then complete the objective in the adfacent box.  Do not repeat the verb as you are typing.
Upon completion of this program, participant will be able to:
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Self Assessment Questions
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2.  
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