Speaker Forms

Speaker Name *

Email Address *

Required entries with every submission*

FACULTY DISCLOSURE See Faculty Disclosure Statements

It is the policy of the GSO/HNS to comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards for commercial support of CME activities. All faculty are required to disclose to the program audience any real or apparent conflict(s) of interest related to this meeting or its content. Having an interest in or affiliation with the corporate organization does not necessarily prevent you from making the presentation, but the relationship must be made known to the audience. Failure to disclose or false disclosure will require the GSO/HNS to identify a replacement for your participation.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for you immediate family as defined above. If an individual is uncertain about what might constitute a potential financial conflict or interest they should err on the side of full disclosure.

Category	Code	Description
Consultant / Advisor	C	Consultant fee, paid advisory boards or fees for attending a meeting (for the past 1 year)
Employee	E	Employed by a commercial entity
Lecture Fees	L	Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial entity (for the past 1 year)
Equity Owner	O	Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial otolaryngology products or commercial otolaryngology services
Patents / Royalty	P	Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant Support	S	Grant support for the past 1 year (all sources) and all sources used for this project if this form is an update for a specific talk or manuscript with no time limitation.

Please select one of the following two options

I DO NOT have any financial relationship to disclose.

I have the following financial relationships to disclose:

Company/Organization:

Code(s): C E L O P S

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation (specify drug(s) or product(s) by name for which the unlabeled use will be discussed.

FACULTY AGREEMENT

The undersigned Faculty (the “Undersigned”) agrees to:

1. Present the session as specified in the course objectives and in the marketing materials of the Georgia Society of Otolaryngology/Head & Neck Surgery (GSO/HNS).

2. Submit all handouts and related materials for the session in accordance with submission deadlines

and requirements.

3. Not engage in any type of promotion, marketing, or selling of any product or service during the presentation which shall in all respects be free of commercial bias.

4. Notify GSO’s Meeting and Education Manager immediately in the event that an emergency prevents the Undersigned from meeting his/her obligations as a speaker.

5. Grant to GSO a nonexclusive, irrevocable worldwide license to reproduce, make derivative works, publish, distribute, and/or sell the recording, transcript, and/or related materials of my presentation. This license does not prohibit the Undersigned from using this presentation in the future for his/her own professional or personal work.

6. Warrant and represent that, to the best of Undersigned’s knowledge, nothing in the presentation violates the personal rights of others (including, without limitation, any copyright or privacy rights), is factual and contains nothing libelous or otherwise unlawful.

7. Warrant and represent that the presentation is the Undersigned’s own original work, that Undersigned has the authority to enter into this agreement, and the Undersigned is the sole copyright holder or that has attained all necessary licenses from any persons or organizations whose material is included or used in the presentation.

8. Authorize GSO to use the Undersigned’s name, likeness, photographic image or biographical data in connection with the use and promotion of the meeting and the presentation.

9. Indemnify and hold harmless GSO from any claims for damages, costs or expenses arising from claims of copyright infringement resulting from the publication, sale, dissemination or distribution of any materials submitted and/or presented by the undersigned, either orally or in writing. The undersigned further agrees to indemnify GSO against any liability from any statements, oral or written, made by the Undersigned during or after this presentation.

I have read the Disclosure Requirements and Faculty Agreement and to the best of my knowledge, the information provided on this form is true and correct and represents all items for disclosure. I understand that failure to comply with the disclosure policy or the faculty agreement, when known and deliberate, may result in disqualification for two years in similar educational or related activities.

Entering your name in the following space acts as my signature and agreement to the above statement: