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If you have questions, please send an email to unclcn@unc.edu or call (919) 445-1000.

This Agreement is made between the UNC Lineberger Cancer Network (UNCLCN) and the presenter.

More information can be found on the APP Presenter FAQ.

I. Engagement

The speaker will present this webinar for UNCLCN Advanced Practice Provider series.

Date: Supplied in emails.

Time: 12:00 – 1:00 PM EST/DST (We ask that you arrive no later than 11:45 AM EST/DST).

Location: UNCLCN Recording Studio (Rooms CM210 and CM167, Manning floor of NC Basnight Cancer Hospital) or connecting via Zoom. When possible, we prefer to host presenters in the studio to ensure optimal production quality.

Would you prefer to present in our studio or remotely from any location by using Zoom?

Remote using ZoomIn the UNCLCN studioPlease talk to me, and we'll decide later

II. Terms of Cancellation

Before cancelling, the speaker agrees to inform UNCLCN (45) days or more prior to the scheduled engagement date. The speaker also agrees to provide the names of alternative speakers to present on the same or a related topic.

III. Speaker Contact Information

We need the following information to communicate with the speaker during the webinar planning process. Please add information and make any corrections below.

Presenter

First Name

Last Name

Credentials

Professional Title

Employer or Organization

Other

Contact Information

We have found it useful to have the speaker’s cell phone number to help solve technical issues before the webinar.

Cell Phone

Preferred email for webinar planning

Address

Mailing Street

Campus Box:

Mailing City

Mailing State

Mailing Zip/Postal Code

Administrative Support

If you have someone who acts in an administrative support role for you, please list details here.

Contact Name

Contact Phone

Contact Email

IV. Video Agreements

Video Agreement

Do you agree to appear on camera?

Yes

No

Are you a UNC School of Medicine employee?

YesNo

Recording Release

Permission to Record and Reproduce - I hereby grant the University of North Carolina at Chapel Hill, School of Medicine, and Office of Information Systems (collectively “the University of North Carolina”), a non-exclusive right to record, using any medium (including, but not limited to, lecture capture, videography, or photography), reproduce, publish, and otherwise make available, my image, including my name, likeness, voice or any combination thereof; and my presentation materials (Materials) and recordings of Materials; including distribution of those recordings and Materials by any tangible or digital media (e.g. print, DVD, memory card, external storage device), or over the internet.

Retention of Copyright by Presenter - I understand that this grant to the University of North Carolina will not alter ownership rights of the Materials in accordance with U.S. Copyright Code, and that I will retain the right to use all or part of the Materials in future works, such as books and lectures. I represent that use of Materials is not in conflict with or in violation of any previously issued permissions or copyrights or is not otherwise illegal. The University of North Carolina will not be held responsible and will not provide any form of legal or financial support if these Materials are in violation of any previously issued permissions or copyrights or used in an illegal.

I understand and consentI do not consent, I do not wish to participate

YouTube and VuMedi

The webinar is recorded and made available in the UNCLCN Online Video Library and in VuMedi. Note: Our YouTube and VuMedi Channels do NOT permit comments or rankings.

Do you agree to have a recording of your webinar included in our UNCLCN Youtube Collection?

Yes

No

Do you agree to have your presentation made available in VuMedi?

Yes

No

V. Required Disclosure Forms and CV

Required Disclosure Forms

Accrediting organizations use these forms to identify and resolve potential conflicts of interest:

• UNC Health Financial Disclosure Form — NCPD/CNE CE credit.

To save time, UNCLCN will take the information provided on this form and complete the other required disclosure forms on behalf of the presenter.

I agree to allow UNCLCN to use information from this form to complete additional accreditation forms on my behalf. This may include minor changes to the webinar description and learning objectives to meet accreditation standards.

Yes

No

Curriculum Vitae/Résumé

A current CV is required for approval by several accrediting organizations.

I would like to upload my CV nowPlease contact me later to email my CV to you

Upload CV/Résumé

VI. Presentation File and Handout

Presentation File with References

Three weeks before the presentation date, we will need the complete slide deck (PowerPoint or Keynote only) for accreditation approval. The following items are needed:

Complete citations for major references used in the presentation
At least one citation that is less than 7 years old
References are to be included on slide(s) at the end of the presentation
3 or more slides with polling questions
Provide prior notice of adding any videos or audio files and include copyright attribution

Webinar Handout

Do you agree to have your presentation slides available in a participant handout?

Yes

No

VII. Fifteen Minute Pre-Webinar Meeting and Scheduled Time Off

We will schedule a 15 minute meeting with you approximately 1-2 weeks prior to the webinar to review the logistics and webinar content.

Do you have any scheduled time off (such as a vacation) in the next two months? If "yes," please share the dates with us so that we can adjust our due dates.

YesNo

Please share the dates with us so that we can adjust our material due dates if necessary.

VIII. Approval of Assessment for Enduring Materials (Self-Paced, Online Courses)

A video recording of the webinar with continuing education credit will be made available as enduring materials in our Learning Portal. We will need your feedback on a 10-question assessment after the webinar.

IX. Accreditation

Please click the button Next Page for Accreditation.

Accreditation: Part I

Name and Credentials

Email Address

Describe your education or experience (more than your title) to support participation in this planning or presenting

Financial Relationship: Any relationship which benefits you financially.

Financial relationships include grants where the money goes to your organization, if you are the Principal Investigator. Financial relationships must be reported even if they have ended; in such cases, the end date should be noted in the Disclosure Grid.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME System are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Ex: pharmaceutical companies, device manufacturers.

Eligible organizations include hospitals, physician practices, diagnostic labs that do not sell proprietary products, education companies (such as Elsevier or UpToDate), insurance companies, software companies (including electronic medical record companies), and government agencies. If you are uncertain about the eligibility of an organization, list it on the Disclosure Grid.

Financial Relationship: Any relationship which benefits you financially. Common types are listed on page 2.

The ACCME has not set a minimum dollar amount for financial relationships to be significant.

Financial relationships include grants where you are the Principal Investigator, even if the money goes to your organization.

Financial relationships must be reported if they have ended within the last 24 months; in such cases, the end date should be noted in the Disclosure Grid.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME System are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Ex: pharmaceutical companies, device manufacturers.

Eligible organizations include hospitals, physician practices, diagnostic labs that do not sell proprietary products, education companies (such as Elsevier or UpToDate), insurance companies, software companies (including electronic medical record companies), and government agencies. If you are uncertain about the eligibility of an organization, list it on the Disclosure Grid.

In the past 24 months, I have not had any financial relationships with any ineligible companies.

Yes, I have had one or more financial relationships with ineligible companies.
(All financial relationships must be disclosed, regardless of relevance.)No, I have NOT had any financial relationships with ineligible companies.

(If you acquire a new financial relationship after submitting this form, you must submit a revised form to UNC CPD immediately. Otherwise, this form is valid for all activities during the current academic year.)

Signature

Please sign and date below and click the button "Submit."

Signature

Date

Accreditation: Part II

Financial Relationship: Any relationship which benefits you financially.

Financial relationships include grants where the money goes to your organization, if you are the Principal Investigator. Financial relationships must be reported even if they have ended; in such cases, the end date should be noted in the Disclosure Grid.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME System are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Ex: pharmaceutical companies, device manufacturers.

Eligible organizations include hospitals, physician practices, diagnostic labs that do not sell proprietary products, education companies (such as Elsevier or UpToDate), insurance companies, software companies (including electronic medical record companies), and government agencies. If you are uncertain about the eligibility of an organization, list it on the Disclosure Grid.

Disclosure of Relevant Financial Relationships

Ownership Interest*

Individuals with a legal duty to act in the company’s best interests.

Excludes stockholders of publicly traded companies or holders of shares through a pension or mutual fund. Provide the name of the ineligible company and the relationship end date**.

Employee*

Individuals hired to work for another person or business for compensation and who are subject to the employer’s direction as to the details of how to perform the job.