Presenter Agreement — Cervical Cancer Screening

Page 1

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


Thank you for agreeing to participate in the cervical cancer screening training module project. As a content expert, your contribution is invaluable in creating high-quality educational materials. This form will guide you through a series of questions to ensure we capture all necessary details for your recording or presentation. By completing this form, you confirm your commitment to this project.

I. Content Recording Preference

Content experts will have the option to record their educational material in a variety of formats. These can be decided at a later date when the instructional design elements are discussed but if you have a strong preference now, knowing so will help guide our planning.


II. Terms of Cancellation

Before cancelling, the speaker agrees to inform UNCLCN (30) days or more prior to the scheduled recording. 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








Address





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



IV. Video Agreements

Video Agreement
Presenters that choose to record their content in front of a camera will be expected to abide by UNC policy for video recording and release. 


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
YouTube and VuMedi

UNCLCN will store any video recording in the UNCLCN Video Libary. Presenters also have the option to make their educational content available on VuMedi and YouTube. Note: Our YouTube and VuMedi Channels do NOT permit comments or rankings.



Educational Handout

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 — NCPD/CNE CE credit.

• UNC School of Medicine Conflict of Interest Disclosure — CME 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. 


Curriculum Vitae


IX. Accreditation

Please click the button Next Page for Accreditation.

Accreditation: Part I

UNC Health logo

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.

Part II must by completed ONLY if a financial relationship with an ineligible company needs to be reported.

Signature

I have carefully read and considered each item in this form and have completed it to the best of my ability.



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

*Employees and people with ownership interests are prohibited from any involvement in planning CME events.  The ACCME also strictly limits their involvement as presenters.  If either of these applies, please be sure to submit your COI form with as much advance notice as possible so UNC Continuing Professional Development (CPD) can 
mitigate the potential effect of these relationships and verify whether your talk is eligible for credit. 

**Financial relationships that were active in the past 24 months but which have since ended must be disclosed, and the end date must be listed.

Enter the Name of Ineligible Company

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.
Enter the 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 even if that individual’s institution receives the research grant and manages the funds.
Has the relationship ended?
If the financial relationship existed during the last 24 months, please include the date which the relationship ended.



Signature

I have carefully read and considered each item in this form and have completed it to the best of my ability.