Willingness to Participate and Disclosure Form

SPA 30th Annual Meeting
October 21-November 7, 2016
Sheraton Grand Chicago Hotel • Chicago, IL

Willingness to Participate and Disclosure Form for: Olga Wolke
If you are not Olga Wolke click here | Return to Faculty Forms.

Contact Information

First Name

Last Name

Academic Title

Academic Institution

Academic Institution City/State

Phone Number

Mobile Phone Number

E-mail Address

Admin Assistant Name

Admin Assistant Email

Willingness To Participate/Adherence To Deadlines

I have read the Willingness to Participate information below. These assignments have been made as a result of an invitation to perform the duties as a faculty member for the above-captioned meeting.

Please indicate your participation in the following lectures, workshops, case discussions, and/or as moderator as outlined in the lecture schedule.

Participation	Date	Lecture Title
I will participate in this lecture I must decline this lecture	Fri, Oct 21, 2016	PBLD # 6: Your patient wants to die: Respecting autonomy and rights of privacy in the critically ill pediatric patient

I am pleased to participate in all lectures, workshops, case discussions, and/or as moderator as outlined in the lecture schedule.

I agree to adhere to all deadlines outlined in my faculty letter/email.

Disclosure Information

Individual's Role(s) in Education (Choose all that reply)

Planner (examples: planning committee, staff, faculty, or content)

Speaker, Session Moderator, Workshop Faculty, PBLD/Round Table Moderator

Reviewer (abstracts, PBLDs)

Other

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at kim@societyhq.com.

Having an interest in or affiliation with any corporate organization does not prevent a faculty member, board member, or committee member from making a presentation or participating in the planning of an educational activity, but the relationship must be made known to the audience in advance.

To be Completed by Planner, Faculty, or Others Who May Control Educational Content
Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

In the past 24 months, I have not had any financial relationships with any ineligible companies.

Enter the Name of Ineligible Company An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.	Enter the Nature of Financial Relationship Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should bedisclosed by the principal or named investigator even if that individual's institution receives the research grant and manages the fund.	Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken.

I, Olga Wolke attest that the above information is correct as of this date of submission.