NDLS Course Faculty Planners Disclosure

Faculty Disclosure

All faculty and planners 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 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 Training Center 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 your immediate family as defined above. If an individual is uncertain about what might constitute a potential financial conflict of interest they should err on the side of full disclosure.

Consultant/Advisor- Consultant fee, paid advisory boards or fees for attending a meeting (for the past 1 year).

Employee- Employed by a commercial entity.

Lecture Fees- Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial entity (for the past 1 year).

Equity Owner- Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufactures of commercial otolaryngology products or commercial otolaryngology services.

Patents/Royalty- Patents and/or royalties that might be viewed as creating a potential conflict of interest.

Grant Support- Grant support of 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.

I have the following financial relationships to disclose.

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 National Disaster Life Support Foundation (NDLSF).

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 the National Disaster Life Support Foundation (NDLSF) Meeting and Education Manger immediately in the event that an emergency prevents the undersigned from meeting his/her obligations as a speaker

5.) Grant to the National Disaster Life Support Foundation (NDLSF) 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 the presentation in future for his/her own professional 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 has attained all necessary licenses from any person or organizations whose material is included or used in the presentation.

8.) Authorize the National Disaster Life Support Foundation (NDLSF) 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 the National Disaster Life Support Foundation (NDLSF) against any liability from any statements, oral or written, made by the Undersigned during or after this presentation.

9.) If there are any changes that would present a conflict of interest as described above, that have not been previously disclosed, I will notify the NDLS Program Office immediately.

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 knowns and deliberate, may result in disqualification for two years in similar educational or related actives.

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