SIR 2019 ACTiVE Workshop Application

HANDS-ON WORKSHOP APPLICATION

Dear SIR Industry Partner:

Welcome to the hands-on program of the 2019 ACTiVE meeting! This is a complimentary opportunity for companies exhibiting in this course.

Please complete the following application to request a place for your company's participation.

Format

Topics:

- Venous interventions (image guidance, thrombectomy, stenting, etc.)

Friday, October 25, 4:00 pm

Salon II

- IVC filters, positioning, retrieval

Saturday, October 26, 11:30am

Salon II

Expect 100+ attendees, primarily practicing interventional radiologists, with other clinical and scientific professionals interested in the treatment of venous thromboembolic disease (VTE) and related health concerns.

Each company is provided a single 6-foot table with electricity to produce a hands-on demonstration emphasizing clinical skills and medical device knowledge.

Demonstrations are led by your company representatives. The experience should be interactive, with ample product for numerous attendees. Complementary flow models, phantoms, visualization tools, and/or medical simulators are highly encouraged.

Requirements

Companies must be registered exhibitors to participate.

There is no fee to participate in these workshops.

Workshops must be kept clear of any branded, trade, or promotional materials. Only clinical, scientific, or instructional publications are allowed.

For each activity, companies must agree to abide by these terms:

Declaration of Independence

Session being applied to in this form (please return to this form to apply for an additional session):

Contact

Company Name

Company Division/Business Unit (indicate N/A if not applicable)

Planning Contact Name

Planning Contact Email

Planning Contact Phone

On-Site Contact Name

On-Site Contact Email

On-Site Contact Phone

Setup

Please provide Product Name, Type, Number of Pieces, and Fair Market Value (FMV) per piece for the primary clinical product(s) (not for incidental or ancillary items like gauze or medical tape). FMV is usually given as List Price, Average Sale Price (ASP), or capital equipment rental. Please use a new line for each item:

For purposes of logistics, documentation and accreditation, SIR requests a list of products your company expects to display. This information will not be released to the public in any way, whatsoever unless and only as permission is granted by your company.

Fair Market Value (FMV) of In-Kind Donation (all pieces in total):

Please provide a non-zero value. Generally accepted standards include List Price, ASP (Average Sales Price), or capital equipment rental rate. SIR is not requesting a donation of equipment for possession by us. Your company leads your own workshop demonstration and retains possession of all materials at all times. The use of your equipment for the purposes of educating our member physicians is considered an in-kind donation. The value of this donation must be recorded by SIR for internal accounting and tax standards as an accredited, not-for-profit society for medical professionals. If you truly believe the material your company is providing has no value, please enter a zero and call SIR to confirm at 703-460-5575. SIR does not compensate your company for any manufacturing, logistical, or staff expenses incurred through providing these materials or attending the session. Your company will be responsible for proper handling of material before, during, and after the workshop, including responsible disposal as appropriate.

Please read the "hint" when you click to edit this item.

Our setup will feature (optional question):

Vascular models (such as silicone or 3D-printed)Synthetic tissue phantomsDigital visualization tools, such as use electric displays or 3D goggles, etc. (The table will be supplied with a standard power strip. Please provide for your own laptop, screen, or other electronic devices. The AV ordering contact can be found on the exhibitor webpage.)Animal tissue phantoms (turkey breast, beef liver, etc. The catering order contact can be found on the exhibitor webpage .)Medical simulators (The table will be supplied with a standard power strip. Please provide for your own laptop, screen, or other electronic devices. The AV ordering contact can be found on the exhibitor webpage.)

Demonstration Models and Simulators

The following companies offer anatomical models, simulators and services in support of experiential learning. Please feel free to consider their offerings when planning your company’s participation

in ACTiVE’s hands-on workshops.

United Biologics, Inc.

Contact: Michael Ghebrial

Email: info@unitedbiologics.com

Office: 949-345-7490

https://unitedbiologics.com/

Authorization

Certification Statement (check one or both selections as appropriate to your company)

I have read and agree to the terms and definitions required by SIR, and I am authorized by my company to make such commitments on its behalf.My company requires an alternative LOA or grant process. I will send instructions and forms promptly to clopez@sirweb.org.

Authorized Signature

Title

Date

Questions

Christian Lopez
Corporate Relations Associate
clopez@sirweb.org
(703) 460-5575