Psychiatry Grand Rounds Presenter Interest Form

Psychiatry Grand Rounds Presenter Interest Form

If you would like to present at an upcoming Psychiatry Grand Rounds, we would love to hear from you. Please fill out the form below and we'll get in touch with you.

Last Name*

First Name*

Title*

Degree*

Email address*

Phone Number*

Phone

Do you have a faculty appointment with OHSU Psychiatry?*

Please note that we do require all those who do not have a faculty appointment with us to work with a faculty member on your grand rounds presentation provided that they are at a doctoral level or above and are sufficiently knowledgeable about your work.

Yes

Proposed Date(s)*

Psychiatry Grand Rounds are typically held the 1st and 3rd Tuesdays of each month.

Proposed Presentation Title*

Proposed Learning Objectives*

Please provide a minimum of three objectives and try to put in context of something the participant can do such as "List, Describe, Demonstrate, Identify, Document, Establish, Provide, Produce, Introduce, Analyze, Administer, Maintain," etc

Brief Bio*

Please provide a brief bio for introductory purposes

Do you have relevant financial relationships?*

YES - I have the following relevant financial relationships with any commercial interests

NO - I do not have any relevant financial relationships with any commercial interests

List Commercial Interests*

Please list those commercial interests which produce health care goods or services and with which you or your spouse/partner either: a) have a relevant financial relationship now, or b) have had a relevant financial relationship during the past 12 months. Non-profit companies, non-health care related companies and governmental organizations do not need to be included. Describe your role in relation to the commercial interest(s) listed. Describe what you or your spouse/partner received (ex: salary, honorarium etc). OHSU does NOT need to know how much you received.

Send me a copy of my responses

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