Biographical & Conflict of Interest Form

Biographical & Conflict of Interest Form (18th Annual Family Medicine Update)

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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
  • 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.
  • Role in Educational Activity: (Check all that apply)
  • 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.


  • Please indicate the teaching methods 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.


  • 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.

    (*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.