5/4/2016
Quillen College of Medicine
CME Activity
Speaker Information
You must have a disclosure slide included in your presentation. If you don’t have one, click this link for some
examples. If you have any questions, let me know. CME Disclosure Slides. (You may have to enter ETSU
username and password twice for them to come up).
Presenters should refrain from using A/V materials for which they do not have copyright or permission for use from the
copyright holder. This includes songs, video, still images, graphics, tables, or other materials which are understood not to
be in the public domain.
Your Demographic Information
1. Your Name and Credentials: (Please complete your
demographic information as you would like to see it
in print)
2. Your Title and Organization and Academic Title,
Department, and Specialty
3. Organizational address, including city, state, and zip,
4. Your phone number, fax number and email address
5. How do you prefer we contact you?
Phone
Email
6. Name of the CME Activity at which you are
presenting:
7. Date of your presentation:
8. Presentation title (as you would like to see it in
print):
9. Name and contact information of your assistant:
Specifics Related to Your Topic
Please give us two to four learning objectives for your attendees (For tips on writing learning objectives click
here: http://www.etsu.edu/com/cme/Learning_Objectives.aspx )
1. “As a result of participating in this activity, the

participant will be able to……”



2.
Which physician attributes (competencies) do you
Patient care
Quillen College of Medicine  East Tennessee State University  Office of Continuing Education  423 439 8081  Page 1
5/4/2016
plan to incorporate into your presentation?
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
Medical knowledge
Systems-based practice
3. What educational format will you use?
Lecture/Presentation
Panel discussion
Group discussion
Case Presentation
Problem solving
Other. Describe:
Measuring Outcomes
Referencing your Learning Objectives above, please provide us with one to two case based scenarios which
we can use with participants to demonstrate their mastery of your topic: (In those few situations where a
case scenario simply does not apply, please substitute with a Q&A). (For tips on writing case scenario
question click here: http://www.etsu.edu/com/cme/studiescase_scenarios.aspx
1. Case description (includes a question at the end for
the participant to answer):
Multiple Choices: A.
(use as many as you wish) B.
C.
D.
E.
Correct Answer
2. Case description (includes a question at the end for
the participant to answer):
Multiple Choices:
A.
B.
C.
D.
E.
Correct Answer
Your Audiovisual and Technology Needs:
We will provide:
 a computer with PowerPoint and Windows Media
 screen
 microphone
 laser pointer
 a handheld device to remotely advance your PowerPoint
 podium
 LCD to project your PowerPoint
Quillen College of Medicine  East Tennessee State University  Office of Continuing Education  423 439 8081  Page 2
5/4/2016
1. What other equipment or audiovisual support will
you need?
DVD player
Audience Response System (Clickers)
Audience Microphone
Other
I will bring my own laptop
Mac
PC
I will bring/provide a DVD/Video Clip
I will need internet access
2.
Yes
No
Would you like for us to contact you regarding your
technology needs?
Conflict of Interest Disclosure & Mutual Accountabilities
Please see original email request for the link to complete the disclosure and
accountabilities requirements.
This disclosure must be made at least once every 12 months, or more often if
relationships with commercial interests have changed at the time of planning/presenting
at an educational event.
This form provides you with the opportunity to submit your disclosure information and
other documentation needed by the Quillen College of Medicine Office of CME for
planners and presenters, in accordance with the requirements of the ACCME, ANCC, and
ACPE.
May We Have Your Permission:
Do we have your permission to
1. I give CME permission to record and/or to send a live
broadcast of the presentation identified above. I
agree to allow CME to use this recording for
education and other related purposes. *Please note,
this recording will be used on our website for up to
two(2) years, unless otherwise specified.*
2. Use the handout from your PowerPoint…
(Please indicate your choice)
Yes
No
Yes No
In a program syllabus?
As a PDF on our website?
Other uses or limitations:
Please save this document for your files and return an attached copy via email to David Nolan and
Karen Bright-Hensley. You may also fax it to us at 423-439-8040. We will notify you that we have
received this document. Thank you for your time and your commitment. Please call us at 423-4398081 if you have any questions.
Quillen College of Medicine  East Tennessee State University  Office of Continuing Education  423 439 8081  Page 3