Speaker Information Form, OSCC ASM, October 10-11, 2024

If you would like to receive a copy of this submission to your email, please enter it here.

Your Session Information

Title of Presentation(Required)

First Name(Required)

Last Name(Required)

Position(Required)

Institution/Company(Required)

Information Required for Accreditation Purposes

1. Overview(Required)

Brief statement of presentation. Sample: "This lecture will describe the chemical and biological role of Maillard reaction and formation of advanced glycation end products in aging and age-related diseases such as diabetes, end stage renal disease and cataracts. New therapies designed to prevent the impact of glycation in these diseases will be discussed." 50 to 120 words

2. Intended Audience Level(Required)

Basic

Intermediate

Advanced

3. Learning Objectives and Outcomes(Required)

State the education objectives for your activity. What will learners be able to do after the activity that they could not do before? Statement must begin with “At the conclusion of this session, participants will be able to …” SAMPLE: Pediatric Poisonings - At the conclusion of this session, participants will be able to: 1) Appreciate the limitations of routine drug screens in identifying overdose in infants and children. 2) Understand the need and use of Advanced Technology for overdoses in the Pediatric Population. 3) Appreciate the importance of interaction with Clinical Staff for correct interpretation. STATE AT LEAST 2 LEARNING OBJECTIVES.

Biographical Information

Upload Brief Biography of Approximately 150-200 Words, For Introduction Purposes(Required)

Max. file size: 30 MB.

Electronic Copy of a Recent Head & Shoulders Photograph(Required)

Max. file size: 30 MB.

Authors Copyright Declaration

Date(Required)

Conflict of Interest Disclosure

A conflict of interest occurs when the financial interests of a speaker/author potentially preclude an unbiased, scientific presentation of a subject. The reason for requesting disclosure of possible conflict of interest is 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. Jones has research support from XYZ instruments,” but will not be used to exclude speakers from a program. All speakers must complete this form.

All speakers in accredited Continuing Education Programs must disclose any possible 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) holds stock in the company, (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.

I have read the above statements and (please select the appropriate choice and sign below).(Required)

I declare that neither I nor any member of my immediate family has a financial interest in a company as defined in the CSCC/OSCC policies on conflict of interest

I (or a member of my immediate family) has a financial interest in a company as defined in the CSCC/OSCC policies on conflict of interest (specify below).

Name

First Last

First Name(Required)

Last Name(Required)

Signature(Required)

Date

Financial Interest Disclosure

1. Grant/Research Support

2. Salary/Consultant Fee

3. Stocks/Bonds

4. Honorarium/Expenses

List company/companies:

Speaker Information Form, OSCC ASM, October 10-11, 2024