Received grants or funds in support of research of (list) diabetes-related company products. Serve as a paid consultant to (list) diabetes-related companies. …
Continuous Quality Improvement CQI Poster Abstract Form
This form is to be used for CQI Poster submissions only A Conflict of
Interest Statement and Biographical Data Form must be filled out for each
presenter Please type all information onto the form no handwritten
entries To move to the next field, hit the tab button on your keyboard,
and type in your text
|CQI Project Title | |
|Limit: 10 words | |
|What was the problem | |
|you identified for | |
|this project? | |
|Limit: 1-3 | |
|sentences | |
|What data did you | |
|collect? | |
|Limit: 2-3
| |
|sentences | |
|How did you analyze | |
|the data? | |
|Limit: 2-3 | |
|sentences | |
|What alternative | |
|solutions did you | |
|consider? | |
|Limit: 2-3 | |
|sentences | |
|What was your | |
|implementation plan? | |
| |
|
|Limit: 2-3 | |
|sentences | |
|How did you actually | |
|execute your | |
|implementation plan? | |
| | |
|Limit: 2-3 | |
|sentences | |
|How have you been | |
|able to maintain the | |
|improvement you | |
|implemented? | |
|Limit: 2-3 | |
|sentences |
|
|Was any funding | |
|provided for this | |
|project? | |
Signature of primary author: Date:
Electronic signatures acceptable for this poster submission
Sign and return the completed forms by May 2, 2008 via fax or e-mail to:
Education Department, AADE, 312-424-2427, or education@aadenetorg
|Please | Primary author |
|indicate: |Secondary author |
FINANCIAL RELATIONSHIP CONFLICT OF INTEREST STATEMENT
Information must be typed directly onto the form not handwritten A
Conflict of Interest Form must be completed for each presenter Presenters
cannot be added at a later date To move to the next field, hit the tab
button on your keyboard, and type in your text Sign and return form by
Mary 2, 2008
|Name / | |
|Credentials |
|
|Title | |
|Employer | |
It is the policy of the American Association of Diabetes Educators to
require faculty for all educational programs to complete the Financial
Relationship Conflict of Interest Statement We ask that you provide
information concerning your services to industry in order to clarify and
accurately present the relationship of the speaker to industry and other
organizations A printed announcement will be included with the
participants materials to identify pertinent relationships that speakers
have with industry partners in order to facilitate the participants
ability to draw informed conclusions regarding each speakers presentation
In addition, this information is required in order to be in compliance
with the FDA and our credentialing bodies This policy will not prevent a
speaker who is affiliated with a diabetes-related company from being a
speaker for AADE
Please identify the following types of relationships:
Received grants or funds in support of research of list diabetes-
related company products
Serve as a paid consultant to list diabetes-related companies
Serve on speakers bureau or otherwise receive honoraria for speaking
or writing on behalf of diabetes-related companies
Receive any other type of financial or material support that could
present a potential conflict of interest
|Company |Relationship |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
Check this box if you have no conflicts to report
This information will be used by AADE
only to inform educational meeting
participants of any significant relationships with diabetes-related
companies or other interested parties
Signature: Date:
Electronic signatures acceptable for this poster submission
|Please | Primary author |
|indicate: |Secondary author |
BIOGRAPHICAL DATA FORM
Information must be typed directly onto the form not handwritten CVs or
résumés provided in lieu of biographical data forms
will not be accepted A Biographical Data Form must be completed for each
presenter Presenters cannot be added at a later date To move to the
next field, hit the tab button on your keyboard, and type in your text
Sign and return form May 2, 2008
|Name / | |
|Credentials | |
|Title | |
|Employer | |
|Preferred address| |
|City / State / |
|
|Zip | |
|Work telephone | |Fax | |
|Email | |AADE | YES NO |
| | |member? | |
|PRESENT POSITION - Description of responsibilities |
| |
|EDUCATION - Basic preparation through highest degree held |
|Institution Name, City,|Major area of study |Degree |Year Degree Awarded |
|State | | | |
| | | | |
| | | | |
| | | | |
|PROFESSIONAL EXPERIENCE - Briefly describe 2-5 professional experiences and/or |
|any research or publications pertinent to this educational activity;
please |
|also indicate years of experience in diabetes care |
| |
| |
|SPEAKER INTRODUCTION - In 3-5 sentences, please list any information you would |
|like used for your introduction prior to your presentation if oral |
|presentation This will be read as written Include degrees, honors, |
|employment, and accomplishments |
| |
———————–
35th Annual Meeting Exhibition
August 6 - 9, 2008 - Washington, DC
