continuing education 33 rd ANNUAL CARRELL-KRUSEN NEUROMUSCULAR SYMPOSIUM Thursday-Friday, February 17-18, 2011 Texas Scottish Rite Hospital for Children 2222 Welborn Street Dallas, Texas 75219 Abstract Deadline: November 29, 2010 For more information email: cmeregistrations@utsouthwestern.edu Call 214-648-7180, Fax 214-648-2317 or visit: www.utsouthwestern.edu/courses C A R R E L L-KRUSEN AWA R D E E R O B E R T L E S H N E R, M. D. Professor, Department of Neurology and Pediatrics George Washington University Principal Investigator, Center for Genetic Medicine Research (CGMR) Children s National Medical Center Washington, DC C O U R S E D I R E C T O R S U S A N T. I A N N A C C O N E, M. D., F. A. A. N. Professor of Neurology and Pediatrics Jimmy Elizabeth Westcott Distinguished Chair in Pediatric Neurology UT Southwestern Medical Center, Dallas, Texas Director of Child Neurology, Children s Medical Center, Dallas, Texas C O U R S E C O-DIRECTOR G I L I. W O L F E, M. D., F. A. A. N. Professor of Neurology and Pediatrics Dr. Bob and Jean Smith Foundation Distinguished Chair in Neuromuscular Disease Research UT Southwestern Medical Center, Dallas, Texas W H O S H O U L D AT T E N D Muscular dystrophy clinic directors, case managers, nurses and members of multidisciplinary care teams Sponsored by UT Southwestern Department of Pediatrics and the Office of Continuing Medical Education in conjunction with Texas Scottish Rite Hospital for Children and Children s Medical Center, Dallas, Texas
BIOGRAPHICAL DATA FORM FOR ACTIVITIES Instructions: Use this format to provide documentation of an individual s expertise as a member of the course faculty (content specialist) for this activity. Submitted information must not be more than 2 pages. Do not attach any additional material. Faculty Name and Degrees: Preferred Contact Address: Number and Street: City, State and Zip Code: Preferred Contact Telephone: FAX: E-mail Address: Present Position (Employer, job title): Education (include basic preparation through highest degree held) Reminder: A degree is awarded from an academic setting; a license is issued by a regulatory agency. 1. 2. 3. 4. Degree Institution (Name, City, State) Major Area of Study Year Degree Awarded Biographical Data Use the space below to briefly describe your professional experience as it relates to your role, as indicated above, in this continuing nursing education activity: (add additional areas as needed that relate to this role.) As Course Faculty I have content expertise in this topic by:
UT Southwestern Medical Center and University Hospitals CONFLICT OF INTEREST DISCLOSURE The University of Texas Southwestern Medical Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians and is an approved provider by the Texas Nurses Association. It is the policy of UT Southwestern Medical Center and University Hospitals to ensure balance, independence, objectivity and scientific rigor in all of its continuing medical and nursing education activities. All planning committee members and presenters/content specialists/authors participating in a UT Southwestern Medical Center or University Hospitals activity must disclose to UT Southwestern Medical Center and University Hospitals any financial relationships that they or an immediate family member may have with any commercial interest in any amount occurring within the past 12 months that create a conflict of interest. A conflict of interest would also occur if you have any potential to benefit personally or professionally from the presentation (work for a proprietary company presenting the learning activity, have written a book about the topic, provided consulting services related to the topic, etc.). An immediate family member is defined as someone with whom you have a relationship involving the sharing of income or assets. The intent of this disclosure is not to prevent a speaker with commercial affiliations from presenting, but rather to inform UT Southwestern Medical Center and University Hospitals of any professional, personal or financial relationships so that conflicts can be resolved prior to the activity. Name: «FIRST» «LAST», «DEGREE» For all disclosures, complete each section, sign and date the last page. Please spell out all acronyms. I or an immediate family member, has a professional, personal or financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the following categories: 1. Employment No, I do not have an employment relationship with a commercial interest to disclose. Yes, I have an employment relationship with 2. Board of Directors/Other Leadership Position No, I do not have a leadership position with a commercial interest to disclose. Yes, I have a leadership relationship with 3. Research Funding No, I do not have research funding from a commercial interest to disclose. Yes, I receive research funding from 4. Paid Consultant or Member of an Advisory Board or Review Panel No, I do not have a consultant or advisory position to disclose. Yes, I have a consultant or advisory board relationship with
5. Speaker s Bureau No, I am not on a speaker s bureau for a commercial interest. Yes, I am on the speaker s bureau(s) for 6. Major Stock or Investment Holder No, I do not have major stock or investment holdings to disclose. Yes, I have stock holdings with 7. Other Remuneration No, I do not have other compensation to disclose. Yes (please list relationship and company name) Signature of Person Disclosing: Date: FDA APPROVED DRUG AND DEVICES ASSURANCE STATEMENT UT Southwestern Medical Center and University Hospitals is required by the TNA and ANCC COA guidelines to instruct you that any discussions regarding the utilization of FDA approved drugs or devices must be within approved regulations. If you discuss the utilization of FDA drugs or devices that are outside approved regulations (off-label or investigational uses), you must clearly delineate this for your audience. Signature of Faculty Disclosing: Date: For UT Southwestern Medical Center or University Hospitals Continuing Education personnel use Only: No relevant relationship(s) to resolve Session will be monitored to ensure conflict does not arise The conflict was discussed with the individual Provided talking points/outline Restricted presentation to clinical data Data, slides added or removed Reassigned faculty s lecture/topic Reviewed content free of sponsorship/commercial bias Notes: Signature of Planner: Date: Please Fax Completed Forms to 214.648.2317 attn: Veronica Mason
33 rd Annual Carrell-Krusen Neuromuscular Symposium CALL FOR ABSTRACTS February 17-18, 2011 Texas Scottish Rite Hospital for Children Dallas, Texas INSTRUCTIONS: All are welcome to submit abstracts. Acceptance will be based entirely upon quality. The abstract, not exceeding 300 words in length, and forms should be submitted in electronic form to Veronica.Mason@UTSouthwestern.edu SPELL OUT ALL ABBREVIATED TERMS AT FIRST USE. Or, if many abbreviations are used, attach a separate sheet listing spelled-out abbreviations. When citing references, provide name of first author, title of book or name of journal and year published. No continuation page, illustrations or tables are to be included. Abstracts must report work not presented or published prior to the meeting. Remember, when preparing your presentation that the discussions are more effective if the case is an UNKNOWN. DISCLOSURE: It is the policy of ACCME that participants in CME activities should be made aware of any affiliation or financial interest that may affect the speaker s presentations. Each speaker must complete and sign the enclosed conflict of interest statement. The faculty members relationships will be disclosed in the handout. ACCEPTED ABSTRACTS: Authors of accepted abstracts will be notified by December 20, 2010. The time allowed for presentations from the platform and posters may vary according to the material presented and the needs of the session. Authors will be notified by the course director. JOURNAL PUBLICATION: Accepted abstracts will be printed in the Journal of Clinical Neuromuscular Disease. CREDIT DESIGNATION: The University of Texas Southwestern Medical Center at Dallas will designate this educational activity for AMA PRA Category 1 Credits. OFF-LABEL USES: Because this course is meant to educate physicians with what is currently in use and what may be available in the future, there may be off-label use discussed in the presentation. Speakers have been requested to inform the audience when off-label use is discussed. HOUSING/ACCOMMODATIONS: Special room rates have been reserved for symposium guests at the Warwick Melrose Hotel. Place reservations directly with the hotel at (214) 521-5151 or (800) MELROSE. Abstract and enclosed forms return deadline: November 29, 2010 Abstract Author s Acknowledgement, Concurrence and Disclosure Statement The authors have read and agreed with the content of this abstract submitted to the 33 rd Annual Carrell-Krusen Neuromuscular Symposium. Acknowledged below is all support for studies relating to the abstract. If, within the past five years, an author or immediate family member has had a substantial personal financial relationship relating to the support of the abstract, this relationship must be described briefly on a separate sheet. Such relationships include salaries, ownerships, equity positions, stock options, royalties, consulting fees and honoraria for speaking, material support and other financial arrangements. All sources of funding support, including public, for the work described will be published with the abstract in the program supplement of the Journal of Clinical Neuromuscular Disease. First Author s Signature: Printed Name: Study Supported by: _ The University of Texas Southwestern Medical Center at Dallas is jointly sponsoring this program with Texas Scottish Rite Hospital for Children and Children s Medical Center. Phone: (214) 648-2154 Fax: (214) 648-2317
33 rd ANNUAL CARRELL-KRUSEN NEUROMUSCULAR SYMPOSIUM ABSTRACT SUBMISSION TITLE OF PAPER (limited to 50 characters): First author (complete address, phone, fax and e-mail address): Print legibly ALL authors names and complete addresses: (300 word abstract for program Do not exceed 300 words or use continuation pages, illustrations or tables.) Please circle the type of presentation you plan: (1) Live/video patient (3) Scientific/case series (2) Poster (4) Biopsy/EMG If accepted, it is understood that this material has not been, nor will be, presented in the same form elsewhere prior to the meeting. INSTRUCTIONS: Please submit 1) Abstract Submission, 2) Disclosure Form and 3) Bio Form either electronically to Veronica.Mason@UTSouthwestern.edu Information about this symposium will be available on Texas Scottish Rite Hospital for Children s website at www.tsrhc.org in the fall of 2010, and the final program and registration form will be available in early 2011. Phone: (214) 648-2154 Fax: (214) 648-2317