COVIDIEN – RESPIRATORY & MONITORING SOLUTIONS
THIRD-PARTY EDUCATIONAL CONFERENCE SPONSORSHIP
SUPPORT APPLICATION
NOTICE TO APPLICANT:






Covidien has strict policies governing relationships with Health Care Professionals and
adheres to the AdvaMed Code of Ethics on Interactions with Health Care Professionals
and Covidien’s Comprehensive Compliance Program Regarding Interactions with
Healthcare Professionals.
Completion of this form is required for all requests for third-party educational
conference sponsorship support (e.g. financial, product).
All conference sponsorship support must first be approved by the Respiratory and
Monitoring Solutions Grants and Compliance Committee (“GCC”) before any funding is
committed to a conference organizer. Any verbal or other statements made by a
Covidien representative prior to GCC approval shall be considered null and void by
completing this application for conference sponsorship support.
Completion of this application is neither confirmation nor agreement by Covidien to
support the requested activity.
Previous support for an educational activity does not guarantee future support.
All parties associated with Covidien issued third-party educational conference
sponsorship support agree to abide by all requirements of the relevant conference
accrediting agency (e.g. ACCME) and the AdvaMed Code of Ethics on Interactions with
Health Care Professionals.
APPLICANT ATTESTATION:
Please also note that by submitting this application you are attesting to the following:






The faculty and content for this educational conference were selected by the conference
organizer and were not influenced, in any way, by Covidien.
Covidien did not influence, in any way, the planning/logistics of this event.
This program demonstrates genuine educational and/or scientific value.
Any conference sponsorship support issued by Covidien will be used to offset the general
costs of producing the educational event.
Conference sponsorship support is not tied, in any way, to the purchase or use of
Covidien products.
Acknowledgement that the full amount requested may not be awarded and partial funding
will be accepted.
1
INSTRUCTIONS:
Complete this form and submit it to RMSGCC@covidien.com at least eight (8) weeks prior to
the scheduled educational conference along with all of the following required attachments:
1. Detailed educational conference agenda
2. Detailed description of offerings included with sponsorship level (booth space,
advertising)
3. If form is being completed by someone other than the conference organizer, include the
conference organizer’s written request for conference support (e.g. letter of invite;
registration form
4. If requesting over $10,000, a detailed program budget
5. W-9 from the conference organizer
**Please note that only complete applications with all accompanying documentation will be
reviewed.**
THIRD-PARTY EDUCATIONAL CONFERENCE SPONSORSHIP
Conference Organizer (Assoc.,
Society, Hospital, etc.) and
Mailing Address:
Name of Conference:
Location of Conference:
Requestor Information and
relationship to Conference
Organizer:
Building:
Name of Requestor
City:
State:
Date(s) of Event:
Conference Size:
Target Audience:
Is Conference registration open
to the general public? If no,
please explain.
Local:
Expected Attendance:
Regional:
National:
Yes
No
(provide explanation)
Accreditation Status:
Institution Type:
Course Accreditation:
Accredited:
CME/CE:
ACCME:
Non-Accredited:
Joint Sponsor:
Other (specify):
AARC:
AANA:
ANCC:
Other (specify):
Total Conference Budget in
U.S. Dollars
$
2
Financial Sponsorship Amount
Requested from Covidien
Other Sponsorship Support (e.g.
product) Requested from
Covidien
Are you requesting Covidien Respiratory and Monitoring
Solutions to be the sole
supporter of this educational
conference?
Has an additional request for
exhibit/booth space been
submitted?
$
Yes :
If Yes, why are you not seeking support from others?
No:
If No, please specify additional sources of support:
Yes :
No: :
If yes please specify amount that will go towards booth (which is separate from the dollars
associated with the conference sponsorship support being requested in this form): $
If the sponsorship includes use of an exhibit/booth space you are required to specify the
Fair Market Value for use of the exhibit/booth from the general conference sponsorship.
Have you received financial
support from Covidien in the
last two years?
Yes :
No: :
If Yes, please check the type of Support Provided:
Educational Grant
Research Grant
Service Agreement
Speaker Engagement
Other: (please specify):
If Yes, describe the support provided and the approximate date provided:
If this Conference Sponsorship
is approved, to what entity
should payment be made?
Conference Organizer Contact:
Name:
Phone:
Email:
Covidien Business Contact:
Name:
Phone:
Email:
3