Biographical & Conflict of Interest Form (Drug Summit)

Biographical & Conflict of Interest Form (PFCC)

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  • Faculty Name * Required
  • Address * Required
  • Please list your administrative assistant's name and contact information (if applicable)

  • Administrative Assistant's Name:
  • (###)###-####
  • Please upload your most current CV/resume
  • Role in Educational Activity: (Check all that apply)
  • Please upload a promotional image for advertising purposes.
  • Presentation Length * Required
    If you are speaking for 15 minute or doing a 45 minute or 1 hour and 15 minute talk, please list presentation time in "other" field.
  • Knowledge-based CPE activity: These CPE activities are primarily constructed to transmit knowledge (i.e., facts). The facts must be based on evidence as accepted in the literature by the health care professions. The minimum amount of credit for these activities is 15 minutes or 0.25 contact hour.

    Application-based CPE activity: These CPE activities are primarily constructed to apply the information learned in the time frame allotted. The information must be based on evidence as accepted in the literature by the health care professions. The minimum amount of credit for these activities is 60 minutes or one contact hour.
  • Presentation Type: * Required


  • Remember learning objectives must be consistent with the above activity type and must be measurable. If your target audience includes both pharmacists and technicians, you must write separate objectives for both audiences that apply to their scope of practice. For a one hour presentation we request a minimum of 3-5 objectives.

    (*List of Acceptable Verbs - Verbs to AVOID while writing objectives: appreciate, enjoy, really understand, be acquainted with, fully appreciate, realize, be aware of, grasp the significance of, remember, be familiar with, sympathize with, believe, know, understand, comprehend, learn)

  • Please list objectives for Pharmacists, Nurses, Doctors, etc.
  • Technician objectives must be different objectives from pharmacists objectives and relevant to their scope of practice. If your talk is only relevant to pharmacists please indicate as "NA" above.


  • Will this presentation discuss off-label use? * Required
    *Off-label use is the practice of prescribing pharmaceuticals or devices for an unapproved indication or in an unapproved age group, unapproved dose or unapproved form of administration.
  • ACPE standards require that all providers assure that all CPE activities include active participation and involvement of the audience. The methodologies employed should be determined by the CPE activity planned objectives, educational content, and the size and composition of the intended audience.

    Please refer to our Active Learning Strategies Guidance Document to help determine which active learning technique(s) you plan to use for your activity.

  • Please indicate the active learning strategies you will be utilizing in your session: * Required




  • Pharmacy accreditation requires that you provide scholarly references. Professional association websites, or generally applicable articles are fine. List DOES NOT have to be all-inclusive of everything consulted for your talk.


  • Learning Assessment

    ACPE standards require that all providers collaborate with faculty to include learning assessments in each CPE activity to allow participants to assess their achievement of the learned content. Completion of a learning assessment is required for CPE credit.

    The provider may select formal and informal techniques for assessment of learning. Informal techniques typically involve participant discussions. Formal techniques, such as tests and quizzes, are typically individualized, written, and graded. The assessment should be consistent with the identified CPE activity objectives and activity type.

    Please refer to our Learning Assessment Document to help determine which learning assessment type is required for your activity.

  • I agree to work with the Continuing Pharmacy Education Office to develop learning assessments consistent with my presentation objectives and activity type. * Required
  • Educational Materials

    ACPE standards require providers to offer educational materials for each CPE activity that will enhance participants' understanding of the content and foster applications to pharmacy practice.

    Guidance
    Educational materials should serve as a guide, provide additional sources of information, and include reference tools usable in practice.

  • I agree to work with the Continuing Pharmacy Education Office to develop educational materials that serve as a guide, provide additional sources of information, and include reference tools usable in practice. * Required