Speaker Information

Speaker Information
First Name*
Last Name*
Degree*
- RPh
- PharmD
- PhD
- MD
- JD
- Other (answer below)
Other Degree
Job Title / Position*
Company/Pharmacy/Organization*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell Phone*
Fax Number
I am planning to participate in the Speaker Panel discussions on Saturday, November 6.*
- Yes
- No

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Presentation Information
Speaker agrees to provide a presentation in accordance with the learning objectives and course description for the program. The speaker’s presentation must meet with this criteria. If you are on a panel, please be sure to work with your co-presenters to construct your talk in a manner that will effectively meet these objectives.
Please list presentation title and your name with credentials as you would like them in print:*
Needs Addressed / Activity Description*
Please provide a short (3-4 sentence) description of what need this presentation will address for pharmacists and/or pharmacy technicians.

How your presentation will lead to better business practices or patient care?

Please specify the intended audience. (150 words)
Which learning assessment component(s) do you plan to present?*
Knowledge-based CPE activity: These CPE activities should be designed primarily for pharmacists and technicians to acquire factual knowledge. This information must be based on evidence as accepted in the literature by the health care professions.
*The Seminar will utilize informal audience response. Please reserve a brief question and answer segment at the end of your session.
- Group Discussion
- Case Studies
- Observations
- Fill-in activities
- Paired practice (role playing)
- Quizzes

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Additional Sources
In addition to your PowerPoint presentation, please include at least 2 additional sources of educational materials as a means to enhance participant understanding of content and foster applications to practice (e.g. reference tools useful in practice, literature studies, informational guidance, key presentation “take home” points, supplemental handouts, etc.) Items may be uploaded.
Supplemental Handouts for Attendees
Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

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Video/Audio Recording
This educational session will be distributed by QCS in a video format. QCS may distribute your recorded presentation through the ACA/ARL websites. ACA may syndicate any live and recorded presentation through SeminarWeb, a third-party hosting site, thereby offering this educational program via the ACA Education Center online library. The recordings will be copyrighted and distributed by ACA and ARL and their video/audiotape provider under Title 17 of the U.S. Code. All claims for royalties in conjunction with the sale of this webinar, DVD/CD’s or handout materials are waived. No distribution of the recordings by anyone other than the ACA, ARL or syndicated state associations will be permitted without your specific, prior permission. Your signature on this agreement represents your consent to the recording of your remarks ACA’s and ARL’s right to copy and distribute them.
Video/Audio Recording Consent*
- I Give My Consent
- I Do Not Give My Consent

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Post-Test Session Quiz Questions
We will be uploading the presentations as an online CE. Please include six (6) multiple choice and/or true/false questions that can be used as test questions. These questions can be submitted at this time or with your powerpoint presentation.
Please provide the correct answer in the box below the question.
New ACPE guidelines require feedback for quizzes. Please provide a one-sentence explanation for each response that demonstrates why that response is or isn't correct.
Question #1
Answer - Question #1
Question #2
Answer - Question #2
Question #3
Answer - Question #3
Question #4
Answer - Question #4
Question #5
Answer - Question #5
Question #6
Answer - Question #6

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Policy of Non-Commercialism
The Conference maintains a policy of non-commercialism in accordance with the American College of Apothecaries, which is the accrediting continuing education provider, in accordance with the Accreditation Council for Pharmacy Education, that states “Continuing pharmacy education activities that provide an in-depth presentation with fair, full disclosure as well as objectivity and balanced.

Appropriate topics and learning activities shall be distinguished from those topics and learning activities that are promotional or appear to be intended for the purpose of endorsing either a specific commercial drug or other commercial product (as contrasted with the generic product/drug entity and its contents or the general therapeutic area that it addresses), or a specific commercial service (as contrasted with the general service area and/or the aspects or problems of professional practice that it addresses).”
Conflict of Interest Disclosure and Equitable and Fair Balance Agreement
The American College of Apothecaries is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education and will be providing the accreditation for the educational programs developed at this seminar. To help us maintain compliancy with ACPE, please review the requirements below as well as the associated deadlines for submission.
Conflict of Interest Disclosure and Equitable and Fair Balance Agreement*
As a speaker and/or continuing education faculty member, I will:

a) ‘Meaningfully disclose’ any relevant interests that may affect the content of the educational activity being offered.
b) Identify and resolve all conflicts of interest prior to the educational activity being delivered to learners.
c) Ensure the content of the educational activity will give a balanced view of therapeutic options to promote improvements or quality in healthcare and not specific proprietary business interests of a commercial interest.

Balanced view means that recommendations or emphasis must fairly represent, and be based on, a reasonable view and valid interpretation of the information available in the subject and that no single product or service is over represented in the educational activity when other equal but competing products or services are available for inclusion.

We collect information from all planners, faculty, and others in control of educational content about all their financial relationships with ineligible companies within the prior 24 months. As defined by ACPE, an ineligible company is one whose those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. Individuals must disclose regardless of their view of the relevance of the relationship to the education.

Exception: Accredited providers do not need to identify, mitigate, or disclose relevant financial relationships for accredited education that is non-clinical, such as leadership or communication skills training.
- I agree to supply this information.
- I have been informed that my presentation falls into the exemption above.
Download Financial Relationship Disclosure Form For Planners, Faculty, And Others
Financial Relationship Disclosure Form for Planners, Faculty, and Others*
Please upload your completed and signed financial Relationship Disclosure Form below.
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.

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Presentation Materials/Guidelines
Speaker agrees to provide QCS with one (1) presentation of no more than 40 slides, per one hour session, to be included on the attendee website provided to meeting attendees. Please use the Official Conference PowerPoint template provided to you to create your presentation. (See presentation guidelines below for additional formatting information.)

Securing permission for use within the slide presentation of any material under copyright is the speaker’s responsibility. Release and/or letters of permission, if required, shall be provided by the speaker to QCS at the time slides are provided.

If you do not wish for your presentation to be included in the distribution to attendees for proprietary reasons, please submit your request in writing to [email protected] no later than thirty (30) days prior to the initial delivery of the educational program. Unless such a written request is received in the time specified, QCS reserves the right to distribute the presentation in an Adobe Acrobat PDF format to all attendees in advance of or following the delivery of the educational program. The presentation must be sent to Donna Reagan at [email protected] on or before the stated deadline.

Distribution of presentation handouts after the due date will be the sole responsibility and expense of the Speaker. After the deadline, more information on providing your own presentation handouts will be provided to you if necessary. Please note, final presentation materials must be received no later than the stated deadline for review and reproduction for distribution to attendees. We are unable to accept any presentations after this deadline. (QCS reserves the right to modify the handout and require re-submission to adhere to ACPE Guidelines).
Guidelines/Presentation
Please follow these guidelines for developing and submitting your PowerPoint presentation:
1. Use the PowerPoint template provided to you.
2. Limit title fonts to Calibri Bold 44, black and text font to Arial Regular 28, black. Text should not be smaller than 18 points to be visible on the screen.
3. Submit handouts and PowerPoint presentations electronically.
4. Include supplement materials for future reference purposes (such as articles or sample forms)
5. Include a bibliography of related literature in your handout, especially if you refer to certain studies or publications in your presentation.
6. No commercial information of any kind —including logos— is to be included in your handout.
7. No videos may be in your presentation.

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Introductory Bio
Please provide a brief paragraph format biography in a Microsoft Word document. This biography will be used to introduce you during the program, included in the meeting syllabus to all attendees, and for promotional purposes to inform potential educational program participants. Upload your bio below.
Upload Your Bio*
Accepted file types: doc, docx, Max. file size: 100 MB.
Photograph Requested
To help us market and promote the conference, we would like faculty to provide an electronic photograph in .JPG or .PNG format. This photo will be used in promotional material about the conference, on the web page, and onsite materials. The photo may be uploaded below.
Upload Photograph*
Accepted file types: jpg, png, Max. file size: 100 MB.

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Compensation/Reimbursement Policy
As a speaker, QCS will provide you with compensation as described below provided that you submit a slide presentation for inclusion in the course syllabus by the stated deadline.

Under the terms of this agreement, speakers will receive compensation/reimbursement as follows:
• Meeting Registration/Honorarium or Donation to the ACA Foundation
Please select one of the following options:
Meeting Registration/Honorarium or Donation to the ACA Foundation*
Please select one of the following options:
- $300 Honorarium plus one complimentary full conference registration with CE.
- $300 Donation to the ACA Foundation on your behalf plus one complimentary full conference registration with CE.
- $150 Honorarium/$150 Donation to the ACA Foundation on your behalf plus one complimentary full conference registration with CE.
I am:*
Please select all that apply.
- an ARL Bio Pharma Customer
- Not a Customer
- an ACA/ACVP Member
- Not a Member
I plan to attend the entire Conference.*
You will receive conference registration information in your confirmation email.
- Yes
- No
Cancellation
In the event the program is cancelled for which the Speaker has been hired, no compensation will be provided to the Speaker.

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Funds Disbursement
QCS agrees to disburse all monies due to the Speaker no later than 6 weeks after the conclusion of the Conference.
Speaker requests that applicable compensation/reimbursement be made to:*
Make check payable to:
Social Security # / Tax ID #:*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Productive Work Environment Policy
It is the policy of QCS to promote a productive work environment and we will not tolerate verbal, physical or other conduct by an employee, agent, contractor, consultant, or representative of the Association that discriminates, harasses, disrupts, or interferes with another’s work performance or that creates an intimidating, offensive, or hostile environment.
Terms
I have read the terms of this Speaker Agreement between QCS and myself for the Quality Compounding Summit, and agree to the terms presented. There are no other terms or conditions to my engagement other than those written here. There can be no changes unless agreed to in writing. Failure to complete this Speaker Agreement will result in the loss of compensation. Failure to comply with the handout requirements described in the Presentation Materials section above will also result in the loss of compensation.
Signed*
Type Full Name
Date*

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Speaker Agreement and Information

Speaker Agreement

Presentation Information

Requirements for CE Presenters

Additional Sources

Video/Audio Recording

Post-Test Session Quiz Questions

Policy of Non-Commercialism

Conflict of Interest Disclosure and Equitable and Fair Balance Agreement

Presentation Materials/Guidelines

Guidelines/Presentation

Introductory Bio

Photograph Requested

Compensation/Reimbursement Policy

Cancellation

Funds Disbursement

Productive Work Environment Policy

Terms

Financial Relationship Disclosure Form

PowerPoint Template & Handouts

Guidelines

Presentation

Upload Session Quiz Questions

Questions & Answers

Conference Agenda

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