ACHA 2019 Annual Meeting Co-Presenter Bio/Disclosure Form
This form must be completed in one sitting.
SUBMIT THIS FORM ONLY ONCE. If you have changes to your form after it has been submitted, please contact Katie Francavilla at firstname.lastname@example.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 instructions above.)
(as submitted by the Primary Presenter for the program)
Primary Presenter First Name
Primary Presenter Last Name
Co-Presenter Bio Information
Enter your information below.
Degree(s) or Certifications
(as you would list them after your name -- e.g., MPH, BSN, CHES)
For student eligibility, refer to link in instructions above.
I intend to register for the ACHA Annual Meeting as a:
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.
Academic Degree(s) and Professional Certifications
List your completed academic degree(s), institution where the degree was earned, and major or specialty area. (e.g., PhD, ABC University, clinical psychology). Also list current professional certifications (e.g., CHES, APN, LPC).
List your publications that are most relevant to the proposed topic (up to 10)
Biographical Qualification Statement
(Example: I have been the principal or co-principal of multiple federally-funded grants focusing on the epidemiology of drug abuse, HIV prevention, and co-occurring mental and drug use disorders. Among my scientific interests has been the development of strategies for preventing HIV and STDs in out-of-treatment drug users.)
Bio statement must state content expertise. Please submit your biographical qualification statement below. Also include any relevant academic appointments, involvement in professional organizations, and/or awards/honors received. Limit 75 words.
I am qualified to give this specific presentation because:
Conflict of Interest
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.
Conflict of Interest Attestation
I have read, fully understand, and agree to adhere to the Conflict of Interest Disclosure Guidelines. (Refer to the link in the instructions at the top of the page.)
Required Disclosure: During the past 12 months have you, or your spouse or partner had a financial, professional or personal relationship (including self-employment and sole proprietorship) with a commercial interest (as defined in the Conflict of Interest Disclosure Guidelines).
Yes, my spouse/partner
Relationship and Company
If you answered yes above, list the full company name and the specific relationship(s) below.
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.
Send me a copy of my responses
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