Elmira Speaker Commitment Form Please fill out your information below and hit submit. All items marked with an asterisk * are required. This information will appear on the event website and in the program book. Name* First Last Suffix Job Title*Email Address*This will not be published online. It’s for internal use only. Cell Phone*This will not be published online. It’s for internal use only.Proposed Lecture TopicsPlease list below the proposed topics/title for your lecture.Presentation Title*Summary of your topic*Please provide a brief 1-3 sentence summary of your suggested topic.Objectives and Needs Assessment*Please provide an objective of your lecture and a needs assessment. This information is mandatory for each lecture.Do you have any scheduling conflicts or restrictions during the conference?*The lectures will take place Thursday, May 12, 2022 from 12:00 – 5:00 PM. If there is a specific time you have a conflict with, please enter it in the box below.YesNoSchedule Conflicts*Please enter your schedule conflicts/request below.Conflict of Interest DisclosureThe Lake Erie College of Osteopathic Medicine (LECOM) must disclose to the program audience any real or apparent conflict(s) of interest of faculty related to the content of their presentation(s). Having an interest or an affiliation with a corporate organization does not prevent a speaker from making a presentation, but the relationship must be made known in advance to the audience in accordance with the Standards of the Accreditation Council for Continuing Medical Education.Do you have any financial information to disclose?*YesNoDisclosure Statement*With respect to my presentation, I do not have any financial arrangement or affiliations with any corporate organization(s) offering financial grants or support or development or sales of products to be discussed in this CME Program. I have no disclosuresDisclosure Statement*I do have a financial interest/arrangement or affiliation with one or more corporate organizations offering financial grants or support or development or marketing of products to be discussed in this CME program. I have conflicts to disclose and they are listed below.Name of Corporate Organization(s)Grant/Research SupportConsultantSpeakers BureauMajor ShareholderOther Financial or Material InterestGuidelines for Presenters*All presenters are asked to adhere to the following guidelines: • Presenters, please arrive 30 minutes prior to your scheduled lecture. • PowerPoint files must be sent to jblackwell@lecom.edu by April 29. • All presentations should be formatted in the 16:9 format and not the 4:3 format. • All presentations will be converted to PDF and posted to the LECOM CME website for all attendees to view. • All presenters are asked to arrive in professional attire. By checking this box, you agree to speak at this event and you agree to the guidelines listed.PhoneThis field is for validation purposes and should be left unchanged.
