STEP 1: SUBMISSION DETAILS

Submission Type: *

Workshop

30 Minute Plenary presentation

45 Minute Plenary presentation

60 Minute Plenary presentation

Please Complete the following

Title:

List 3 learning objectives:

Provide a short (max 250 words) description:

STEP 2: PRESENTATION DETAILS

1. Has the content of this session been presented at a conference before? *

Yes

Not Sure

STEP 3: PRESENTER INFORMATION

1.) Role *

I am the primary presenter.

I am submitting on behalf of the primary presenter.

2.) Primary Presenter (all correspondence will be via primary presenter)

Full Name *

Address *

Email *

3. List all co-presenters (if any)

If other, please describe.

STEP 4: DECLARATIONS

The Conference Planning Committee will review each conflict and assess the nature and mitigation of potential conflicts where possible.

5. I /we have the following conflicts of interest to declare (select ALL that apply and for each please provide a description of the conflict of interest.

Financial or other affiliation with any for profit or not for profit organization

Membership on Advisory Board or Speakers Bureau

Funded Grants, Research or Clinical Trials

Holds a patent for a drug or device

Any other investment or relationship that could reasonably be seen as having the potential to influence the content of the education session.

Potential Conflicts.

6. I /we agree to include a Conflict of Interest declaration slide at the beginning of the presentation, to email it in advance of the presentation to the CAFCN when requested, as well as make a verbal statement to confirm the same.

Yes

7. I /we intend to make therapeutic recommendations for instrument, treatments or devices that have not received regulatory approval.

Yes

8. I /we have received funding to develop or present this talk.

Yes

9. I/we will be using presentation material including slides, graphics or handouts which were obtained from a pharmaceutical company, device manufacturer, or other industry source.

Yes

10. I / we acknowledge that the topic, title and learning objectives were developed solely by me / us.

Yes

If No, please elaborate about the contributors:

11. I / we acknowledge that a practicing foot care nurse was involved in the design, development, or delivery of this presentation.

Yes

If no, please explain how you have ensured that the presentation meets the needs of foot care nursing.

STEP 5: ACKNOWLEDGEMENTS

Check ALL the boxes to acknowledge compliance with guidelines.

I / we acknowledge that any description of therapeutic options uses GENERIC NAMES only OR both GENERIC and TRADE NAMES. The use of TRADE Names alone is not acceptable.

Wherever appropriate, the relevant evidence will be incorporated into the presentation.

The educational design of the presentation will endeavor to include a discussion on barriers to change that are encountered in practice.

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