NASBS Constructive Criticism Video Session Step 1 of 6 16% Thank you for your interest in submitting a video to the NASBS Constructive Criticism Session. Please fill out all fields for the video upload. If you have any questions regarding the content of the video or about the session, please contact Adam Folbe at [email protected]. If you have technical issues while attempting to upload your video, please contact [email protected]Name(Required) First Last Degree(s) Institution(Required)Email(Required) Cell Phone(Required)Video Title(Required)Would you like your identity to be revealed to Dr Adam Folbe who will screen all submissions?(Required) YES NO Would you like your identity to be revealed to the audience during the Session?(Required) YES NO Do you allow NASBS to store your video in a library on its website for educational purposes?(Required) YES NO If you said YES to the question above, do you want to be identified as the surgeon?(Required) YES NO Technical Points:If you would like, mention here the specific technical points you would like the Expert assigned to your Video to address during the session:Please make sure your edited video follows these guidelines: • The entire edited video should be 5 minutes or less • The first 1 minute or less should have a presentation of the patient history/examination/imaging and other investigations • The bulk of the video should consist of the surgical procedure itself (macro and/or microscopic views). You decide whether you should include patient positioning and macro portions before the microscopic/endoscopic portion • It is optional but preferable to include postop imaging • The Video submission should be in one of the following formats: MPEG, Quicktime, MP4, H.264, AVI • Voice over narration is optional, but preferable • Videos may not include advertisement or promotion of products • Please DO NOT include any music, video clips or other materials/media copyrighted by any entity other than yourself. For example, please do not include classical music from a CD in your collection • 3D Videos will not be accepted As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), NASBS must insure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational activities. We are required to identify and resolve all potential conflicts of interest with any individual in a position to influence and/or control the content of CME activities. A potential conflict of interest is considered to exist if the individual and/or their spouse or partner has received financial benefit in any amount from a commercial interest involved in the activity within the past 12 months. A commercial interest is defined as any proprietary entity producing health care goods or services, with the exception of non-profit, government organizations or providers of clinical service directly to patients. All disclosure information will be reviewed to determine if a potential conflict of interest exists. Additional information may be requested to make this determination. Any changes in the disclosure information prior to the presentation should be forwarded to the NASBS office.Please indicate if you have any relationships with industry to disclose. If you answer "Yes" to the below, we will need to collect the company information on the next step.(Required) Yes, I or my spouse have at present or have had within the last 12 months a relevant financial relationship with a commercial interest. No, I or my spouse have NOT had within the last 12 months a relevant financial relationship with a commercial interest. First RelationshipCompany(Required)What was Received?(Required)SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above(Required)What was your Role with the Company(Required)EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MembersOtherPlease explain your choice of "other" above(Required)Is this relationship relevant to your participation(Required) Yes No You answered YES to the question above, so now we need to resolve any potential conflict of interest.(Required) The financial relationship does not relate to the content of my educational assignment/presentation. I will be using best available published evidence to support my presentation. I am changing my relationship with the commercial interest. All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysis I suggest that my presentation be peer reviewed prior to the activity date. Other Unsure Please fully explain your choice above.(Required)Add a second disclosure? Yes Second RelationshipCompany(Required)What was Received?(Required)SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above(Required)What was your Role with the Company(Required)EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MembersOtherPlease explain your choice of "other" above(Required)Is this relationship relevant to your participation(Required) Yes No You answered YES to the question above, so now we need to resolve any potential conflict of interest.(Required) The financial relationship does not relate to the content of my educational assignment/presentation. I will be using best available published evidence to support my presentation. I am changing my relationship with the commercial interest. All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysis I suggest that my presentation be peer reviewed prior to the activity date. Other Unsure Please fully explain your choice above.(Required)Add a third disclosure? Yes Third RelationshipCompany(Required)What was Received?(Required)SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above(Required)What was your Role with the Company(Required)EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MembersOtherPlease explain your choice of "other" above(Required)Is this relationship relevant to your participation(Required) Yes No You answered YES to the question above, so now we need to resolve any potential conflict of interest.(Required) The financial relationship does not relate to the content of my educational assignment/presentation. I will be using best available published evidence to support my presentation. I am changing my relationship with the commercial interest. All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysis I suggest that my presentation be peer reviewed prior to the activity date. Other Unsure Please fully explain your choice above.(Required) Confirmation(Required) By checking this box I certify the preceding information is true and correct. I further agree that I will communicate any changes in my industry relationships to the NASBS as soon as possible. NameThis field is for validation purposes and should be left unchanged.
