2020 SMRT Speaker Declaration Form

SPEAKER INFORMATION

Name*

First Last Credentials (e.g., R.T., RN, M.D., etc.)

Institution*

Email*

I. PARTICIPANT AGREEMENT: OBSERVANCE OF SMRT POLICIES

Please check each box below to acknowledge that you have read and understand each section, and will satisfy all of your obligations and responsibilities as a meeting speaker.

The content of CE activities does not promote the proprietary interests of any commercial interests.
Content of CE activities will be restricted to pure science, industry issues and operation of devices, and should not include product or company names unless essential (and subject to guidelines below).
Required documents will be submitted as specified.
All recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.
All scientific research referred to, reported or used in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection and analysis.
Unlabeled Uses of Products: When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity, the speaker is required to disclose that the product is not labeled for the use under discussion or that the product is still investigational.
Generic and Trade Names: Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If trade names are used, those of several companies should be used rather than only that of a single manufacturer.

II. DECLARATION OF FINANCIAL INTERESTS OR RELATIONSHIPS:

The SMRT is committed to:
1. ensuring balance, independence, objectivity and scientific rigor in all Continuing Education programs, and
2. presenting CE activities that promote improvements or quality in healthcare and are independent of the control of commercial interests.

Therefore, it is the policy of the SMRT that any speaker making a presentation, or other person having influence over the content of a program designated for Category A Continuing Education Credit must disclose any financial interest or other relationship (i.e., grants, research support, consultant, honoraria, etc.) that the individual may have (or have had within the last 12 months) with the manufacturers, distributors or providers of any commercial products or services that may be discussed in the presentation. This disclosure requirement extends to interests/financial relationships or spouses/partners. It does not apply to relationships with non-profit or governmental bodies.

All participants with any influence on the content of any CE programs are expected to disclose any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education activity. This pertains to relations with pharmaceutical companies, biomedical device manufacturers, or other companies whose products or services are related in a significant way to the subject matter of the presentation.

SMRT does not imply that such financial interests or relationships are inherently improper or that such interest or relationships would prevent the person from participating. However, it is required that such financial interests or relationships be identified so that participants at the CE activity may have these facts fully disclosed, and may form their own judgments about it.

INSTRUCTIONS

First, indicate in the Declaration Statement whether or not you have a relevant financial interest or relationship.

Second, if you have relevant financial interests, give the names of relevant commercial entities below. A drop-down list of some company names is provided. If the particular company does not appear on this list, please enter the name in the space provided. Relationships with non-commercial entities such as universities, hospitals, government agencies, foundations and non-profit societies are not to be included.

After you have provided the name of the relevant commercial entity, provide a description of the relationship. Drop-down lists are provided. The SMRT does NOT want to know how much you received. Please do not provide the amount.

DECLARATION STATEMENT:

Check 1 OR 2 below, whichever applies to you.*

1. I have no actual or potential conflict of interest in relation to the subject/content of this program.
2. I have a financial interest/arrangement with one or more organizations that could result in or be perceived as a real or apparent conflict of interest in the subject of my presentation/the program. (If you have checked "2" please give names of companies/organizations and types of relationship below).

If you have checked 2 please describe financial interests/relationships in the space provided below.

Are the commercial entities with which you have relationships relevant to the content you are planning, developing or presenting for this activity?*

Yes, they are relevant
No, they are not relevant

Declarations

1. Company/Organization

(choose from drop down menu)

Company Other:

Type of Relationship

Choose from drop down menu.

Relationship Other:

2. Company/Organization

Choose from drop down menu.

Company Other:

Type of Relationship

Choose from drop down menu.

Relationship Other:

3. Company/Organization

Choose from drop down menu.

Company Other:

Type of Relationship

Choose from drop down menu.

Relationship Other:

If you have any other financial interests or relationships, please note them in the space below:

III. PERMISSION TO RECORD AND/OR LIVE STREAM:

In continuation of the recent ISMRM/SMRT initiative to increase the value of our meetings to registrants, the SMRT 29th Annual Meeting in Sydney will be recorded and made available to meeting registrants via our SMRT eLearning Center. In addition, some sessions will be live streamed to a virtual audience. The presentations will be made accessible to the MRI radiographer and technologist community after the meeting and may be offered for a fee at the discretion of the SMRT. The presentations may be used for continuing education courses for SMRT.

Please select one:*

A. I give permission for my presentation to be recorded and/or live streamed and made available to the MRI radiographer and technologist community via the SMRT eLearning Center for future viewing and possible sale. The presentations may be used for continuing education courses for SMRT.
B. I give permission for my presentation to be live streamed but NOT recorded and made available as described above.
C. I do not give permission for my presentation to be recorded or live streamed and made available as described above.