GCC Instructor Info Forms

Clinical Conference Instructor Information Form

Thank you for coming here to complete the Instructor Forms for the Clinical Conference. There are twelve sections which need to be completed:
1. Instructor Information
2. PowerPoint Submission Deadline
3. Audiovisual Needs
4. Lecture Objectives
5. Protection of Patient Confidentiality Agreement
6. Commercial Support Standards to Ensure Independence Agreement
7. Instructor Disclosure Agreement
8. Copyright Agreement
9. Hotel Accommodation Request
10. Instructor Expense Information
11. Social Media Marketing
12. Electronic Signature
You will be prompted to complete each section; those highlighted in red are required. After completing the form and entering your digital signature, click the "SUBMIT" button and you will be taken to a page confirming that your information has been received. You will receive a copy of the form by email as well. If you have any questions regarding this form or lecturing at the Clinical Conference, contact Lara Beer-Caulfield.
1) INSTRUCTOR INFORMATION
Enter your first and last names, including any titles/designations
Street Address 1
Street Address 2 (STE, Apt.)

Address

Street Address
Street Address 2
City	ST
Zip Code	Country

Instructor Email (to receive a copy of this form)
Day of Event Phone Number
Area CodePhone Number
2) DEADLINE FOR SUBMISSION OF POWERPOINT
As a speaker at the Clinical Conference, we require you to provide to us a copy of your PowerPoint for the event by October 16. You can submit the files as PDF (preferred) or PowerPoint, but no Key files can be accepted. The files will be reviewed by the Foundation's Compliance Coordinator to ensure there is no bias or commercial interests represented in the lecture content.

Additionally, PDFs will be made available for meeting attendees to download. The Foundation has received negative feedback in the past about handouts when speakers do not provide their handouts.

Files should be uploaded to Dropbox by October 16. Note that you are still required to bring your presentation to the meeting on a flash drive or your personal laptop- the uploaded files are not provided to the AV company for use at the meeting.
Acknowledge your acceptance of the Submission of PowerPoint Agreement by selecting "YES":

Yes, I have read and acknowledge the content of the Submissions of PowerPoint form and will submit my PowerPoint(s) by October 16, 2025.
3) AUDIOVISUAL NEEDS
All presenters are required to bring their PowerPoint file(s) to the Clinical Conference on a flash drive and the AV tech on-site will load the PowerPoint from your flash drive. You will not be able to use your own computer during your presentation.

Note that the PowerPoint or PDF of your PowerPoint that is required by October 16 will not be provided to the AV company for the meeting- we understand that you may make changes to your presentation after you've submitted your files to us and want you to make sure you have the most up-to-date file that you use for your presentation.
Acknowledge your acceptance of the Audiovisual Needs form by selecting "YES":

Yes, I have read the above statement and agree that I will bring my PowerPoint presentation(s) on a flash drive from which the AV tech will load for the presentation(s).
An LCD projector, LCD Panel/Screen, wireless microphone, and laser pointer will be provided for every lecture. Additionally, WIFI will be available on-site at the event and during the lectures. If you require additional audiovisual needs, please list them here:
ADDITIONAL AV NEEDS
4) LECTURE OBJECTIVES
Lecture objectives are clearly defined and measurable statements that indicate what a participant is expected to accomplish upon completion of the lecture. A learning objective expresses a specific, short-range outcome and is stated in behavioral or action-oriented terms.

A lecture objective is NOT what you, as the speaker, hope everyone will learn from your presentation.

Tips on how to write effective objectives:

Appropriate Verbs for Learning Objectives:
- Comprehension: Assess, classify, compare, contrast, demonstrate, describe, differentiate, explain;
- Application: Apply, calculate, develop, operate, practice, prescribe, select, solve, translate, use, utilize;
- Analysis: Analyze, appraise, debate, deduce, diagram, distinguish, measure, question, summarize;
- Evaluation: Critique, determine, estimate, evaluate, judge, rank, recommend, revise, score, test;
- Those that impart skills: Administer, demonstrate, diagnose, diagram, employ, integrate, measure, operate, palpate, process, project, record;
- Those that convey attitudes: Acquire, consider, encourage, exemplify, modify, plan, reflect, revise;
- Those that convey information: Cite, define, identify, list, quote, repeat, state, tabulate, trace, update.
Do not use the following words: Appreciate, know, learn, increase, improve, understand, become, expand, and believe as they are vague and open to many interpretations. Objectives beginning with these words cannot be readily measured.
Select which lecture these objectives apply to (lectures are listed in alpha order by speakers LAST name):
At the conclusion of this lecture, the attendee shall be able to:
Objective 1 (required)
Objective 2 (required)
Objective 3
This section applies to speakers: Canzanese, DeSimone, Emerel, Evans, Hummel, Kwaadu, Le, Malay, Meyers, Nasser, Rowe-Bauer, Taweel, and Woodley.
For those speakers who have a second lecture at the meeting, select which lecture these objectives apply to (lectures are listed in alpha order by speakers LAST name):
At the conclusion of this lecture, the attendee shall be able to:
Lecture 2, objective 1
Lecture 2, objective 2
Lecture 2, objective 3
5) PROTECTION OF PATIENT CONFIDENTIALITY
As the creator of your PowerPoint file(s) to be presented at this conference, it is your responsiblity to ensure that all patient protection standards are in place to maintain confidentiality. Applicable primarily to the photos/videos used in your PowerPoint, as well as in discussion of cases and patient care, you ensure that you:

• Obtain prior written informed consent from the patient
• Utilize aseptic conditions and appropriate equipment and instruments
• Ensure that instructors provide sufficient clinical supervision
• Provide continuity of care
• Provide emergency services

The material(s) presented and/or distributed shall be in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended.
Protection of Patient Confidentiality Acknowledgement

I acknowledge that I have protected the confidentiality and care of my patients as described in the above statement.
6) COMMERICAL SUPPORT STANDARDS TO ENSURE INDEPENDENCE
In compliance with CPME standards, the following policies apply to all instructors and their presentations for Goldfarb Foundation conferences. The policies must be acknowledged by all instructors, regardless of whether funds from an unrestricted educational grant will be used to support your participation in the event.
1. Educational materials that are part of a continuing education activity, such as slides, abstracts and handouts, cannot contain any advertising, trade name or a product-group message. Specific lecture titles cannot contain a trade name.
2. The content or format of a continuing education activity or its related materials must promote improvements or quality in healthcare and not a specific proprietary business interest or a commercial interest.
3. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names from several companies must be used, not just trade names from a single company.
4. An individual must disclose to attendees any relevant financial relationship(s), to include the following information: The name of the individual; The name of the commercial interest(s); The nature of the relationship the person has with each commercial interest. The Foundation will make this information known during the introduction of each speaker by the moderator and in the meeting program. The disclosure information will be taken from your Instructor Disclosure Form.
5. For an individual with no relevant financial relationship(s) the attendees must be informed that no relevant financial relationship(s) exist. The Foundation will make this information known during the introduction of each speaker by the moderator and in the meeting program.
6. 'Disclosure' may include the use of a trade name but not a product-group message.
Some of the above verbiage has been taken from CPME 720 and The ACCME Standards for Commercial Support^SM, Standards to Ensure Independence.
Acknowledge your acceptance of the Commercial Support Standards to Ensure Independence form by selecting "YES" below:

Yes, I have read and acknowledge the content of the Commercial Support Standards form.
7) INSTRUCTOR DISCLOSURES

Disclosures will be made to meeting participants in the event program and prior to your lecture(s)

I/my partner DO NOT have an actual or potential conflict of interest in relation to my presentation(s)

I/my partner DO have an actual or potential conflict of interest in relation to my presentation(s)

If you selected above that you/your partner do have an actual or potential conflict, list the name of the company/commercial interest(s) for each disclosure you are making.

Blank	Myself	Spouse/Partner
Major Stock/Share Holder
Speakers' Bureau
Consultant
Grant/Research Support
Other Financial/Material Support

8) COPYRIGHT AGREEMENT
I acknowledge to the Goldfarb Foundation that the presentation(s) noted above, to be presented by me at the Goldfarb Clinical Conference, are free from copyright infringements.

I acknowledge that I have:

- Not infringed on any copyrighted material

- Received permission to use any and all copyrighted material from the owner of the work

- Utilized my own copyrighted work.

I acknowledge that copyright materials within a presentation may include, but are not limited, to:

- Written works

- Drawings/cartoons/photographs

- Music

- Video/Film/TV

- Spoken word.

I represent to the Goldfarb Foundation that the presentation(s) referenced herein is my/our own original work, does not infringe upon intellectual property rights of any third party and that I/we have the full right to make this release and license. I agree to indemnify and hold harmless the Goldfarb Foundation, its officers, employees and agents for any breach of this representation.

9) HOTEL ACCOMMODATIONS
HOTEL INFORMATION: The Goldfarb Foundation will make reservations for you at the Casino Resort Tower (newly renovated!) if we receive your paperwork by the deadline. If your travel expenses are covered by an unrestricted educational grant, the Foundation will make your hotel reservations but you will be required to pay for the room yourself as reimbursement is provided with your honorarium check. If a grant is not covering your travel expenses, your room and tax (parking is free) will be billed to the Foundation’s master account but you will be required to present a credit card at check-in for incidentals.

Suggested arrival and departure dates are based upon the days that you will be lecturing AND ARE LISTED ON THE HARD COPY OF THE FORM. If you see an "Room may not be required" listed for the arrival or departure date on the form, it means that we are assuming you will not need a room and you can confirm that by selecting that under "Arrival Date".

PLEASE NOTE: If you require a reservation for days outside of what the Foundation deems to be a reasonable amount of time related to your speaking engagement, please note those details below. The Foundation will make one reservation for all of your needs and instruct the hotel to charge the appropriate night(s) to the master account and the additional nights to your personal credit card which you’ll provide at check-in. Example: Bob Smith, DPM is speaking on Friday morning at the conference but wants to stay through Sunday at the hotel. The Foundation will pay for his room on Thursday night but he’ll be responsible to pay for Friday and Saturday nights. The Foundation will make his reservation for arrival on Thursday, departure on Sunday. Dr. Smith will present his credit card upon arrival at the hotel and when he checks out on Sunday, will have paid for any Thursday incidentals, plus room, tax, and incidentals for Friday and Saturday nights.
ARRIVAL DATE
DEPARTURE DATE
10) INSTRUCTOR EXPENSE INFORMATION
HONORARIUMS: The William L. Goldfarb Foundation pays its instructors at a rate of $350.00 per lecture hour unless funding through an unrestricted educational grant is arranged. The honorarium rate remains the same regardless of the educational activity format (in-person, virtual, hybrid). Honorariums will be distributed after each speaking engagement. Any honorariums that are not distributed before the Instructor’s departure will be sent via UPS Ground immediately following the end of the conference. All honorariums must be approved by the Goldfarb Foundation. For more details about unrestricted educational grants, see the enclosed documentation. With unrestricted educational grants, the commercial source will provide a check to the Foundation and the Foundation will then issue the instructor a check for their honorarium and travel expenses as outlined within this policy. If a grant is applied for and not approved, the Foundation will pay for your travel expenses and honorarium as outlined on this page.

OVERNIGHT ACCOMMODATIONS: The Foundation will make overnight hotel reservations for each instructor. The number of nights covered depends upon the number of days the instructor has been invited to lecture. Please note that each instructor will be required to present a credit card to the hotel for incidentals upon check-in. The Foundation will not be financially responsible for any incidentals unless prior permission has been granted. If you choose to extend your hotel stay beyond what the Foundation will pay for, you will be required to make, and pay for, those accommodations separately.

REIMBURSABLE EXPENSES:

AIRFARE: The William L. Goldfarb Foundation will pay for air travel utilizing coach only. The cost to upgrade to a higher class must be paid by the instructor. The instructor is responsible for making their flight arrangements at least 6 weeks before the start date of the meeting. Reservations made less than four weeks in advance of the conference and/or more than $450.00 (roundtrip) must be approved by the Foundation. Airline reservations made exceeding $450.00 without prior approval from the Foundation will only be reimbursed up to $450.00.  A baggage fee of up to $25 each way is allowed per instructor. The Foundation will not pay for supplementary fees including “premium” seats with more legroom, early boarding opportunities, reserved seating (such as on Southwest), and other add-ons that the airlines have created since this policy was written.

PERSONAL AUTO: Mileage will be reimbursed at a rate of $.70 per mile.

OTHER TRANSPORTATION: Appropriate tolls and parking expenses will be reimbursed with receipts.  Transportation to/from Philadelphia International Airport varies, from Uber to private transfer. If you are flying into PHL for the meeting, please contact Kelsey Rasmussen (kelsey@ppma.org) to discuss airport transfer options.

MEALS: A meal allowance of up to $124/day is provided for which you will be able to claim on your expense report. The allowance is to cover meals (breakfast, lunch, and dinner) that are NOT provided. Receipts must be attached to the expense form to be reimbursed.

OTHER DETAILS:

•     The Foundation will provide complimentary registration to instructors for the Friday-Sunday general Clinical Conference lectures. Instructors can register themselves at the published attendee non-discounted registration prices for the APMA Coding Seminar and Risk Management Update.

•     The Foundation will not reimburse the expenses of family members or guests accompanying the instructor.

•     Original receipts and documentation must be submitted on a Foundation Expense Form within 30 days of the Conference to receive reimbursement.

•     The Foundation agrees to reimburse instructors according to the above policies. Checks will be issued within 30 days of receipt of the Expense Form. The instructor will be notified if circumstances prevent the Foundation from meeting this deadline.
Acknowledge your acceptance of the Instructor Expense Information form by selecting "YES" below:

Yes, I have read and acknowledge the content of the Instructor Expense Information Form.
11) SOCIAL MEDIA AND EVENT MARKETING
The Goldfarb Foundation is eager to market the Clinical Conference on social media and needs your help! Drop your social media details below so we can tag you in our event posts. We are also looking for instructors willing to make a short (30 seconds or less) video talking about their upcoming lectures at the Clinical Conference to promote interest in the meeting. Thank you for your help!
I have the following social media accounts:

Facebook
Instagram
LinkedIn
TikTok
I do not have any social media
Facebook handle
Instagram handle
LinkedIn handle
TikTok handle

I want to make a promo video!

I'd love to make a promo video for my lectures at the Clinical Conference, please pass my info along to the marketing contact.

Thank you for the option, but I will pass on this opportunity.

12) ELECTRONIC SIGNATURE
Electronic Signature (use your mouse or finger to sign)
Reset
For those speakers who have a third lecture at the meeting, select which lecture these objectives apply to (lectures are listed in alpha order by speakers LAST name):
At the conclusion of this lecture, the attendee shall be able to:
Lecture 3, Objective 1
Lecture 3, Objective 2
Lecture 3, Objective 3
11) UNRESTRICTED EDUCATIONAL GRANTS
If you are aware of an unrestricted educational grant that may be available to the Foundation in support of our meeting, please contact Lara Beer-Caulfield no later than September 1, 2024, in order for the grant application process to occur.
If your web browser auto-fills your name into the sections below, please remove it.
If applicable, please check which type of disclosure(s) you need to make and then list the relevant names of the companies/organizations.
Commercial Interest(s) you have an actual/potential conflict in/with:

Major Stock/Share Holder
Speakers' Bureau
Consultant
Grant/Research Support
Other Financial/Material Support
Name of commercial interest(s) you own stock in or are a shareholder of:
Name of commercial interest(s) who you consult for:
Name of commercial interest(s) whose Speakers' Bureau you are on:
Name of commercial interest(s) who provide you grant/research support:
Name of commercial interest(s) who provide Financial/Material Support to you:

1) INSTRUCTOR INFORMATION

2) DEADLINE FOR SUBMISSION OF POWERPOINT

3) AUDIOVISUAL NEEDS

4) LECTURE OBJECTIVES

At the conclusion of this lecture, the attendee shall be able to:

At the conclusion of this lecture, the attendee shall be able to:

5) PROTECTION OF PATIENT CONFIDENTIALITY

6) COMMERICAL SUPPORT STANDARDS TO ENSURE INDEPENDENCE

7) INSTRUCTOR DISCLOSURES

8) COPYRIGHT AGREEMENT

9) HOTEL ACCOMMODATIONS

10) INSTRUCTOR EXPENSE INFORMATION

11) SOCIAL MEDIA AND EVENT MARKETING

12) ELECTRONIC SIGNATURE

At the conclusion of this lecture, the attendee shall be able to:

11) UNRESTRICTED EDUCATIONAL GRANTS

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