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Speaker Information Form

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Meeting Accreditation ID(Required)

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Your Session Information

Listing in Program

Title of Presentation(Required)

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. 80 to 120 words

2. Intended Audience Level(Required)

Basic

Intermediate

Advanced

3. Learning Objectives and Outcomes

State the educational 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 …” – STATE AT LEAST 2 OBJECTIVES/OUTCOMES.

SAMPLE:
Pediatric Poisonings
At the conclusion of this session, participants will be able to:

Appreciate the limitations of routine drug screens in identifying overdose in infants and children.
Understand the need and use of Advanced Technology for overdoses in the Pediatric Population.
Appreciate the importance of interaction with Clinical Staff for correct interpretation.

Enter Learning Objectives Here(Required)

Biographical Information

Upload Brief Biography of Approximately 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/Conflict of Interest Declaration

For accreditation purposes, all speakers 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. This disclosure is not to censor or exclude speakers, but to inform the audience so that they may decide for themselves whether or not a presentation is biased.

I, the undersigned, agree to include a disclosure slide listing possible conflict of interest at the beginning of my presentation.

I, the undersigned, the author of this presentation, certify that I have obtained all customary and necessary permission to use and print any copyright material that appears in my presentation.

I agree that the Canadian Society of Clinical Chemists may make my presentation available to individuals who may be interested in accessing it by posting it on the CSCC National Website.

Signature(Required)