BTOG Faculty Acceptance Form

For all BTOG educational events

"*" indicates required fields

Name*

First Last

Email*

Enter Email Confirm Email

BTOG Event Title*

Invitation acceptance*

I understand that by checking this box, I accept the invitation to participate in the BTOG educational event.*

Declaration of Conflict of Interest

BTOG Conflict of Interest Policy is available here.

BTOG requires that the 1st slide of your presentation following the title slide includes your declaration of conflict of interest – please include this even if the declaration you make is nil.

A conflict of interest may mean financial, investment, licensing or other commercial interest in the subject matter under discussion or under review. The reportable time period in all cases is within 2 years of the event date or review date. Where the conflict of interest relates to a BTOG event please submit with your acceptance to participate or within 1 month of the date of the event.

Employment or leadership (FT, PT, service as officer or board members)
Advisory role
Stock ownership
Honoraria for speech, presentation or appearance
Sponsorship
Research funding – relating to clinical research being discussed
Expert testimony
Other remuneration including trips, travel, gifts, in-kind payments (excluding research related costs)

Select one option*

I wish to make a conflict of interest declaration.

I confirm I have no conflicts of interest to declare.

Please list all conflicts of interest.

BTOG views funding from tobacco and related industries as against BTOG’s aims and objectives.

Select one option*

I do not have a relationship with any tobacco or related industries.

I do have a relationship with tobacco or related industries.

Please list details of your relationship with tobacco or related industries.

Faculty Permissions

Presentation Slides (choose one option)*

I confirm that I am the sole author of the presentation slides. I confirm that any claims or liabilities arising from infringement or alleged infringement on intellectual property or any other legal issue arising and related to your presentation slides are my sole responsibility and I duly indemnify and hold BTOG harmless.
I give permission to BTOG to publish a copy of my presentation slides on the BTOG website in the Resources Library and where relevant on www.BTOGwebinars.org or related BTOG conference/meeting platforms. If not provided prior to the event I agree to submit a copy of my presentation slides to BTOG for these purposes ASAP after the date of the event.

Not applicable: Tick here if you are participating as a Chair or Moderator

*BTOG notes that sometimes presentation slides may include confidential data and therefore you can submit an amended version of the presentation for inclusion in the BTOG resources library. On submission of your presentation slides you must indicate if you intend to submit an amended version to be published. Please note editing of audio/video is not possible for the purposes of the removal of presented information/data.

Audio/Video Recordings and Use of Image/Biography

AV permission

I give permission to BTOG to record the audio and video portion (if any) of the session/presentation and for recordings to be published as above. I also give permission for the use of my image and biography in relation to the BTOG educational event and also in advertising for the event.

Declaration*

I understand that checking this box serves as an electronic signature for the purposes of this form and all its contents. If left unchecked, I will not be allowed to participate in the BTOG educational event. I declare that the details included on this form are true and accurate.

Date*

BTOG Faculty Acceptance Form

Declaration of Conflict of Interest

Faculty Permissions

Audio/Video Recordings and Use of Image/Biography

Declaration*

Contact

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