ELMC2 Presenter Agreement

"*" indicates required fields

Instructions

You must complete all REQUIRED fields and hit the SUBMIT button (at the bottom of this page) in order for your information to be captured. Upon successful submission, you will receive a confirmation email.

Name*

First Last

Credentials*

Limit to highest advanced degree earned and one certification of your choice. Board of Certification (BOC) credentials must be consistent with BOC guidelines - www.ascp.org/boc.

Affiliation/Workplace*

List your professional affiliation as you would like it to appear in the program (Note: only one institution or company name will be listed in the program.) Please only list your institution; do not include your title.

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Mobile Phone*

Title of Presentation*

Presentation Description*

Used in promoting presentation; please limit to 2 - 3 sentences.

Level of Instruction*

This assists the potential attendee determine if the program will be suitable for their level of experience with the subject. *Basic: Entry level; no prior knowledge of subject necessary *Intermediate: Refresher course; some basic knowledge required; for the experienced staff technologist with some years of experience *Advanced: Highly technical; for those with current skills/knowledge and extensive experience in a specialty area

Presenter Introduction*

Please provide pertinent information that relates to this session/topic. This background information will be used to introduce you at the beginning of your presentation. Please limit biographical information to 50 words or less.

Presenter Headshot

This image will be uploaded to our event app and associated with your speaker profile. Some images will be used on our website to highlight sessions.

Max. file size: 360 MB.

Learning Objectives

Provide 3 different learning objectives for your presentation by completing this sentence: “At the conclusion of my presentation, participants will be able to….” Learning objectives must be measurable, so please begin with words like “Identify”, “classify”, “summarize”, etc. Please refrain from beginning objectives with the verbs "understand," "learn" or "know."

Learning Objective 1*

Learning Objective 2*

Learning Objective 3*

Disclosure of Conflicts*

The possibility for bias or a conflict of interest occurs when the financial interests of a speaker/author potentially preclude an unbiased, scientific presentation of a subject. The disclosure of possible conflict of interest is requested not to censor or exclude speakers, but to inform the audience so they may decide for themselves whether or not a presentation is biased. Information from this declaration will be disclosed to participants as follows: “Dr. Smith has research support from ABC Technology, Inc.” but will not be used to exclude speakers from an activity. ASCLS requires all speakers in accredited Continuing Education Activities to disclose any possible bias or conflict of interest regarding the topic that is being presented. A conflict of interest is defined as any financial interest of the speaker in a company's products or services discussed in the presentation. For example, if the speaker (1) directly holds stock in the company (not including mutual funds), (2) is paid salary or consultant fees by the company, (3) has grant support from the company, and/or (4) has received support for travel expenses, honoraria, etc., from the company, a conflict of interest exists regarding this topic and must be reported. If the speaker has a financial interest in a company but is not discussing a product or service of that company, no conflict of interest must be disclosed. Please select the appropriate statement below as it relates to the topic of your presentation within the preceding 12 months:

Please provide any information on stocks, Consultant Fees, Grants/Research or Honorariums/Expenses.*

By submitting this form, you are agreeing that you understand and accept the terms of your participation as stated in this agreement, financial disclosure and the Presenter Guidelines & Information.