ACHA 2024 Annual Meeting Poster Co-Presenter Bio/Disclosure Form

This form must be completed in one sitting. SUBMIT THIS FORM ONCE FOR EACH SESSION YOU ARE CO-PRESENTING. If you have changes to your form after it has been submitted, please contact Katie Wilkins at kwilkins@acha.org. Required fields are indicated by a red asterisk“*”

 

I understand and agree to adhere to the General Policies for Presenters, including the proper or required content of slides. (Refer to link in ACHA web page instructions or contact your primary presenter.)

 
 

Program Information

(as submitted by the Primary Presenter for the program)

 
 
 
 
 

Co-Presenter Bio Information

Enter your information below. *Note: The Program Planning Committee will not be given presenter or co-presenter names or institution/employer names. Please make sure you provide complete biographic/demographic information below so that they have as much information as possible as they make their selections.

 
 
 

As you would list them after your name (e.g., APN, LPC, CHES)

 

List your completed academic degree(s), institution where the degree was earned, and major or specialty area.


Example: PhD; ABC University; Clinical psychology

 
 
 
 
 
 

Presenter Qualifications

Please provide complete information in this section, as presenter qualifications factor heavily in the decision-making process of the program planners and continuing education reviewers.

 

As you prepare your bio statement, please do not put "See CV" or other attachment. Consider the following when preparing your response:


  • Write in the first-person tense and do not include your name or institution.
  • Clearly state your content expertise related to the topic of your presentation.
  • Include relevant academic appointments, involvement in professional organizations, and/or awards/honors received.
  • Specify the number of years you’ve been working on the program initiative, topic area, or specialty.
  • Describe your involvement in implementation of research, initiative, topic area, or specialty.
  • Indicate whether you have presented on this topic before. (If you would like to submit your CV for specifics, you can upload at the bottom of this form.)



Example: I have been working as a Psychologist in our Counseling Center for five years. My dissertation was on identity development among trans students. In my current role I primarily work with trans students, and I serve as the Co-Investigator of this study. I have presented about this research on-campus and at other national conferences.


I am qualified to give this specific presentation because:

 
 
 

Area of Practice (past or present)

Check all that apply related to yourself.

 
 
 
 
 
 
 

If your area of practice is other, please specify

 
 

Institutional Demographics

Check all that apply related to your institution. If you are not at an institution of higher education, you may skip this section.

 
 
 
 
 
 
 

If other, please specify

 
 

Indicate below the student population of your institution. If you are not at an institution of higher education, you may skip this section.

 
 

Policy

ACHA is obligated to the organizations that grant us CE accreditation/approval to ensure that all educational activities are developed and presented with independence, objectivity, and scientific rigor. It is our responsibility to ensure that they are free from promotion of specific goods or services, and that they are free from actual or potential bias.


All faculty/presenters/authors/planners are required to disclose all financial relationships with any ineligible companies (defined below) that you have had over the past 24 months, regardless of the amount and regardless of whether you view the financial relationships as relevant to the education. The Program Coordinator will identify and mitigate, as appropriate, any relevant relationships and the presence or absence of relevant financial relationships for all persons in control of content will be disclosed to the participants/learners before the learner engages in the education.


Please note: The identification of financial relationships with ineligible companies does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity.

 

I have read, fully understand, and agree to adhere to the Conflict of Interest Disclosure Guidelines outlined above and below.

 

Disclosure of Relationships

Definitions


Ineligible Company: The ACCME defines an ineligible company as any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Additional entities that are considered by ACHA to be ineligible companies include for-profit entities that develop, produce, market, or distribute products and services that promote wellness, and that provide administrative products and/or services used in student health.


Relevant Relationship, as defined by ACCME and ANCC, are relationships with an ineligible company, if the products or services of the ineligible company are related to the content of the educational activity.


Nature of the Financial Relationship: Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator ev

 

During the past 24 months have you had a financial, professional or personal relationship (including self-employment and sole proprietorship) with a company (as defined above).

If you have a financial relationship with a company but aren’t sure whether it fits the definition above, it’s best to check yes and include the information.

 

If you answered yes above, list the full company name(s) and the nature of relationship(s).

 
 

If you indicated the name of company above, does the CE content over which you have control contain information about healthcare products or services of the ineligible companies you identified?

 

Will your presentation include discussion of off-label, experimental, and/or investigational use of drugs, devices, medical procedures, or interventions?

 
 
 

By typing my name below, I am providing my electronic signature indicating that all the information entered in this Program Submission Form is accurate. I further attest that I will not promote any products, goods, or services, or bias the educational activity in any manner.