SIR RFS Clinical Education Faculty Form

SIR RFS Clinical Education Faculty Form

Thank you for your participation with the SIR Resident and Fellow Section (SIR RFS). Please take a few moments to complete the faculty agreement form.

Contact Information

Designation * Dr.Mr.Mrs.Ms.

Full Name: *

Institution: *

Email *

Phone #:

( )

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Speaker Agreement

This form serves two principal purposes: 1) to give the Society of Interventional Radiology the non-exclusive right to audio- and videotape your presentation and use and/or sell the recording and accompanying handouts and other presentation materials (such as PowerPoint slides) in any manner on a royalty-free basis following the presentation; and 2) to assure the Society that your presentation and accompanying materials are your own original work, that you have obtained any necessary copyright permissions, that the work does not infringe anyone else’s copyrights and is not defamatory, that you have the full right and ability to make this license, and that you agree to hold the Society harmless from any lawsuits resulting from the inaccuracy or breach of these assurances.

Please note that this agreement is merely a non-exclusive license, giving us permission to use your written and spoken words following the presentation; it does not in any way transfer ownership of this intellectual property to us and does not in any way restrict your ability to use or profit from the intellectual property in the future. Thank you in advance for your valuable contribution.

Consent to Record

I provide consent for the Society of Interventional Radiology to record my presentation in audio and/or visual form. I understand that the Society of Interventional Radiology will be the sole copyright owner of the recording and can distribute and sell it, along with any supporting materials. Upon request, the Society of Interventional Radiology will provide me with one complimentary copy of the recording, however, I agree not to sell, distribute, stream over the Web, or otherwise use the recording in any way other than for my personal, archival use, except with the prior written consent of the Society of Interventional Radiology. * I agreeI do not agree

Please explain:

License

I grant to the Society of Interventional Radiology a royalty-free license to use, reproduce and distribute my presentation (including all handouts and PowerPoint presentations) in any way in the future, with appropriate attribution to me. I understand that this license does not change the fact that I retain copyright ownership of my presentation, and does not prohibit me from using my presentation in any way or from allowing others to use it. * I agreeI do not agree

Please explain:

Copyright

To the best of my knowledge, my presentation does not violate any proprietary or personal rights of others (including any copyright, trademark and privacy rights), is factually accurate, and contains nothing defamatory or otherwise unlawful. I have the full authority to enter into this agreement and have obtained all necessary permissions or licenses from any individuals or organizations whose material is included or used in my presentation. * I agreeI do not agree

Please explain:

Authorization

I authorize the Society of Interventional Radiology to use my name, likeness, photograph, and biographical data in connection with the use and promotion of the program. * I agreeI do not agree

Please explain:

HIPAA & IRB Compliance

For work performed in the United States, I certify that this report complies with all Institutional Review Board requirements at the institution(s) where the work was performed, and that all regulations of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 were followed. * YesNoNot applicable

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