2026 Annual Meeting – Faculty Information Form - Washington State Neurological Society

Thank you for accepting our invitation to participate on the faculty of the WSNS 2026 Annual Meeting.

1Speaker Information

2Financial Disclosure

Speaker Information

Please complete the information below as you would like it printed in our promotional materials.

Check What Best Describes You(Required)

Speaker / Faculty

Planning Committee

Name(Required)

First Last Credentials (MD, PhD, etc.)

Professional Title(s)(Required)

Institution / Hospital / Company(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Cell Phone Number(Required)

*Cell phone for emergencies only

Personal Email(Required)

To prevent important meeting information from going to your junk/spam folder or being blocked by your institution.

Introduction Bio

Upload Current CV

Drop files here or

Accepted file types: pdf, doc, docx, pages, Max. file size: 256 MB.

Headshot

Drop files here or

Accepted file types: jpg, png, gif, Max. file size: 256 MB, Max. files: 1.

Presentation Details

Title of Lecture(Required)

Date

Honorarium(Required)

The WSNS honorarium is $250.00 per lecture hour. Please choose from the following options:

Please defer my honorarium and donate it to the WSNS

Please provide the honorarium as offered.

I would like a one night stay at the Marriott

Audio / Visual

We ask that you bring your presentation on a UBS Flash Drive. For your presentation, WSNS will provide a podium, microphone, screen, LCD Projector, and laptop computer.

Thank you, but I prefer to use my own laptop.

My presentation includes embedded audio and/or video.

Other A/V Requests

Activity Gap Analysis

The following section MUST be completed for CME documentation purposes. Should this section not be adequately addressed CME for this activity may not be awarded.

Title of Presentation(Required)

Professional practice gap:

Please describe the professional practice gap that underlies the need that your talk will address for the intended target audience. (The difference between current practice and best practice is the professional practice gap.) What do attendees need to learn?

Where did you find your information?

Objectives:(Required)

Ideally, objectives should be stated in behavioral terms, not solely knowledge-based. They should describe what, at the end of this activity, do you want your learners to be able to do?

Add more objectives by clicking the (+) button to the right.

Disclosures

Financial Relationships

The WSMA collects information from all planners, faculty, and others in control of educational content about all their financial relationships with ineligible companies within the prior 24 months. An ineligible company (AKA commercial interest) is defined as a a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Note: Organizations that provide clinical services directly to patients are not considered commercial interests (e.g., group medical practices, for-profit hospitals, health insurance providers, government organizations, etc.).

There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with commercial interests. Individuals must disclose regardless of their view of the relevance of the relationship to the education. Add lines as necessary.

Glossary of Terms

Ineligible company: The ACCME defines an “ineligible company” a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. The WSMA refers to ineligible companies as “commercial interests.”

Relevant financial relationships: Financial relationships are relevant if the educational content an individual can control is related to the business lines or products of the ineligible company. The WSMA reviews all disclosure information and works with activity planners to identify relevant financial relationships.

Mitigation: The WSMA works with activity planners to select and take steps to prevent all those with relevant financial relationships from inserting commercial bias into content, following WSMA and ACCME policy and accreditation expectations.

Initial here if you have NO financial relationships to disclose.

Step 1:

List financial relationships.

If you have, or have had, a financial relationship within the past 24 months with a company that produces, markets, sells, re-sells, or distributes health care products used by or on patients, list them here.

Step 2:

Describe what you received.

Examples: salary; royalty; consulting fee; honoraria; ownership interest, excluding diversified funds (e.g., stocks, stock options); intellectual property rights; research funds; other financial benefit

You do not need to disclose how much you received.

Step 3:

Describe your role.

Examples: employment; management position; independent contractor (including contracted research); consulting; speaking or teaching; membership on advisory committee or review panel; board membership; other activities (please specify)

Disclosures

To add more, press the (+) button to the right. Please use a new line for each COMPANY

Company Name

What was received?

For what role?

Content Validation Attestation

I attest that I will meet WSMA’s Content Validation Policy, which requires the clinical content of educational activities to support safe and effective patient care, using the following methods:

All recommendations for patient care in accredited continuing education must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.(Required)

I attest

All scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.(Required)

I attest

Evolving or controversial topics need to be clearly identified as such within the program and individual presentations. The education must not advocate for, or promote, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning.(Required)

I attest

Activities cannot be accredited if they advocate for unscientific approaches to diagnosis or therapy, or if their education promotes recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.(Required)

I attest

Fair and Unbiased Planning and Presentation Attestation

I attest that my planning and/or presentation will be fair and unbiased. I understand that this can be accomplished, in part, through the following methods:

Use of generic names. If the CME educational material or content includes trade names, where available trade names from several companies should be used, not just trade names of single products.(Required)

I attest

Unless this is a product which has no comparable alternatives, the educational content should list all like products, including pros and cons.(Required)

I attest

Reference sources, ideally peer-reviewed journals, for any clinical recommendations.(Required)

I attest

All content for this activity will be free from marketing. No logos of commercial interests are allowed in any educational materials.(Required)

I attest

I attest that I understand the above statements and I will abide by all rules, standards and guidelines of the WSMA with regards to AMA PRA Category 1 Credit™.(Required)

Your participation will be confirmed after your disclosure form is reviewed by the WSMA. Staff may contact you for clarification about your disclosure information. Refusal to submit a completed disclosure form will disqualify you from participating as faculty.

Supporting the practice of neurology in Washington state

Supporting the practice of neurology in Washington state

2026 Annual Meeting – Faculty Information Form

Speaker Information

Presentation Details

Activity Gap Analysis

Disclosures

Financial Relationships

Glossary of Terms

Step 1:

Step 2:

Step 3:

Content Validation Attestation

Fair and Unbiased Planning and Presentation Attestation