American Association of Oral & Maxillofacial Surgeons
Webinar Application FormCHECKLIST:
Completely fill out and sign application. Incomplete, handwritten, or unsigned applications will not be
reviewed.
Attach a typed presentation outline. List the title of the presentation exactly as noted on theapplication form.
Attach current CV or biographical sketch per presenter.
Complete Financial Relationships Disclosure Form per presenter (page 6).
Please retain a copy of your application and email, mail or fax your completed application to:
AAOMS
Attn: Katie Brower
Staff Associate, Continuing Education
9700 W. Bryn Mawr Avenue
Rosemont, IL 60018
Phone: 847/233-4390
Email: kbrower@aaoms.org

Page 1 of 6American Association of Oral & Maxillofacial Surgeons
Webinar Application Form
Please read the following information carefully and thoroughly before completing the form.
Applications without all required information will not be considered. Please type all information.
Contact Information:
Primary presenter’s name and credentials:
Address:
City:
Phone:
Email:AAOMS Member: Yes
No

State:

ZIP:(Optional)
Secondary presenter’s name and credentials:
Address:
City:
Phone:
Email:AAOMS Member: Yes
No

State:

ZIP:

Presentation Status:
New: The information is being considered for a first-time presentation.
Revised: The information reflects revision of previously presented material.
Repeat: The program has previously been presented at AAOMS meetings.
Clinical Topics:

Please select the single category you feel most appropriately covers your topic.
Anesthesia
Cleft and Craniofacial Surgery
Cosmetic Surgery
Dental Implants
Dentoalveolar
EthicsInfection
Medicine
Nerve Repair
Obstructive Sleep Apnea
Orthognathic Surgery
Pathology

Reconstruction
TMJ
TraumaOther:

Practice Management Topics:

Please select the single category you feel most appropriately covers your topic.
Coding and billing
Communication
Computers and technology
Emergency preparedness
Financial management
Hazard planning

Webinar Length:

Infection control
Inventory management Legal
Marketing & practice building
OSHA, HIPAA andother regulatory requirements

Personnel admin.
Practice organization
Risk prevention
Social media
Team building
Other:
Patient safety and performance improvement
Retirement and estate planning

60 minutes (Clinical)

Preferred Presentation Time (Central Time):

90 minutes (Practice Management)
Morning
Page 2 of 6

MiddayEvening

Presentation Title:
Presentation Synopsis (limit to 100 words):

Target Audience:
Oral and Maxillofacial SurgeonsOral and Maxillofacial Surgery Residents
General Dentists and/or other dental specialists
OMS Staff (Clinical or Practice Management)
Other (please describe):

What is actuallyhappening

The GAP(What is the underlying problem or issue
in practice that you want toaffect/change with this activity )What is optimally supposed tohappen

The purposes of this information is to link each professional practice gap identified to an educational need for this education,then to each objective to the outcome being measured

Current Practice
What is the current practice of OMSs, and if applicable additional target audience members?

Better or Best Practice
What is the current standard of care for the topic area? (as defined by AAOMS or otherguideline/documentation) What should OMSs and if applicable additional target audience members bedoing?

What is the Gap in Learning?
(Based on the current practice vs. the best practice?)

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Presentation Objectives:
Review examples of how to complete this section here.
After completing this program, the attendee should be able to:
Example: Discuss the risks and benefits of a zygomatic implant.
1. Required:Type of change:☐Knowledge ☐Competence ☐Performance ☐Patient Outcomes

2. Required:Type of change:☐Knowledge ☐Competence ☐Performance ☐Patient Outcomes

3. Required:Type of change:☐Knowledge ☐Competence ☐Performance ☐Patient Outcomes

4.

Type of change:☐Knowledge ☐Competence ☐Performance ☐Patient Outcomes

5.

Type of change:☐Knowledge ☐Competence ☐Performance ☐Patient Outcomes

Indicate the method(s) or source(s) used to identify the professional practice gap and the underlying
educational needs addressed by this activity: (Check all that apply. Documentation is required.)
Evaluation of previous CDE/CME activities
Expert opinion (i.e. minutes or meeting report)
Focus group
Literature research
Morbidity and mortality statistics
Other:

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New advances
Review of clinical data
Review of performance; peer review
SurveyTest of knowledgeConflict of Interest or Dual Commitment:

The AAOMS Board of Trustees has determined that dual commitment should not restrict any presentation provided thatappropriate disclosure of such commitment is made. Dual commitment has been defined as a simultaneous commitment
to commercial interests related to the subject of a specific scientific/educational activity, such as special customer
preferences; financial interest; consultantships; governance; research contracts; ownership of patents, companies, royalties,
stock options or equity; past/present employment of immediate family or relatives.
Each presenter of an accepted program must sign the attached Financial Relationships Disclosure Form. Failure tocomplete and return the form will delay review of the application until such form is received by AAOMS.

The presentation is to impart an idea, concept, or philosophy on a particular topic. The presenter is to prepare thepresentation in a generic nature and the presentation is not to contain oral or written reference to the name of a particularcompany or product whether the presenter has any commercial ties or not. The presenter may NOT make reference to aparticular company or product, except as is required to describe scientific information.
Do you or your associate speaker have a dual commitment in the program material?:

Yes

No

Representations and Warranties:

All presenters must represent and warrant that any materials utilized, distributed or presented, including, but not limited
to, handouts, electronic presentations, oral commentary or materials in any other format or medium, will not infringe on
the copyrights or trademarks held by another. All presenters must represent and warrant that any materials utilized,distributed or presented, including but not limited to handouts, electronic presentations, oral commentary or materials inany other format or medium will not constitute an invasion of privacy, a violation of patient privacy laws or libelous
and/or slanderous behavior.

Signature of Understanding and Compliance with AAOMS Policies:

I fully understand that my signature on this application will serve as my representation and warranty that any materials
utilized, distributed or presented during the program, including, but not limited to, handouts, electronic presentations, oral
commentary or materials in any other format or medium, will not infringe on the copyrights or trademarks held byanother. It will also serve as my representation and warranty that any materials utilized, distributed or presented during theprogram, including but not limited to, handouts, electronic presentations, oral commentary or materials in any otherformat or medium will not constitute an invasion of privacy, a violation of patient privacy laws or libelous and/or
slanderous behavior.
In the event of a breach of any of the above mentioned representations and warranties, my signature will serve as myagreement to hold AAOMS and its officers, directors, employees and agents harmless from any claim or cause of action,
including court costs and attorney’s fees, resulting from such a breach. I attest that I have sufficient indemnification
coverage or insurance to protect both myself, the AAOMS and any directors, officers, employees or agents of AAOMS in
the event of any legal action brought against the AAOMS related to any a tort claim, copyright infringement claim or any
other claim brought against the AAOMS related to my presentation.
I also fully understand that my signature on this application will indicate my understanding that AAOMS holds copyrights
on all promotional materials and on the AAOMS website.
My signature will serve as my agreement to allow AAOMS to reproduce, duplicate or distribute any materials utilized,
distributed or presented, including but not limited to, handouts, electronic presentations, oral commentary or materials inany other format or medium during my program.
Furthermore, my signature on this application will serve as my confirmation of my understanding of and agreement todisclose any conflict of interest or dual commitment.
Additionally, I grant AAOMS permission to reproduce, duplicate or distribute materials utilized, distributed or presented
during the program.

________________________________________________________________________________________________________Signature of Primary Presenter

Date:

Signature of Secondary Presenter

Date:

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AMERICAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS

Financial Relationships Disclosure Form
For Faculty, Authors, Committee/Board Members, and Staff
Organizations accredited by the American Dental Association Continuing Education Recognition Program (ADA CERP) and Accreditation
Council for Continuing Medical Education (ACCME) are required to identify and mitigate all potential conflicts of interest with any individual in aposition to influence and/or control the content of CDE/CME activities. A conflict of interest will be considered to exist if: (1) the individual,individual’s spouse/partner, or other immediate family member has a ‘relevant financial relationship;’ that is, he/she has received financialbenefits of any amount, within the past 24 months, from a ‘commercial interest/ineligible entity’ (an entity producing, marketing, re-selling, ordistributing health care goods or services consumed by, or used on, patients), and (2) the individual is in a position to affect the content ofCDE/CME regarding the products or services of the commercial interest/ineligible entity.
All individuals in a position to influence and/or control the content of AAOMS CDE/CME activities are required to disclose to theAAOMS, and subsequently to learners: (1) any financial relationship(s) they have with a commercial interest/ineligible entity within thepast 24 months, or (2) if they do not have a financial relationship with a commercial interest/ineligible entity. PLEASE DISCLOSE ALL
FINANCIAL RELATIONSHIPS. AAOMS WILL DETERMINE IF ANY RELATIONSHIPS ARE RELEVANT TO THE ACTIVITY.
For all faculty participating in the educational activity, disclosure and mitigation must occur before presentations are made or enduring
materials finalized. Faculty are required to complete and return disclosure forms no later than 60 days prior to the presentation of theeducational activity.
Failure to provide disclosure information in a timely manner prior to the individual’s involvement will result in the disqualification of thepotential Faculty, Author, Committee/Board Member, or Staff, from participating in the CDE/CME activity.
Title of CDE/CME activity: ___________________________________________________________________________
Name:_____________________________________________________ Date: ________________________________

Please check one to indicate your role:___ Faculty
Phone Number: _____________________________________ E-mail: ______________________________________DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 24 MONTHS OF DATE OF THIS FORM____ Neither I, nor my spouse/partner, nor any other member of my immediate family, has a financial relationship or interest(currently or within the past 24 months) with any entity producing, marketing, re-selling, or distributing health care goods or services
consumed by, or used on, patients.
OR____ I have or ___ my spouse/partner or other immediate family member has a financial relationship or interest (currently or within
the past 24 months) with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, orused on, patients. The financial relationships are identified as follows (if needed, attach an additional list):
FINANCIAL RELATIONSHIP(S)(check all that apply)
Commercial/Ineligible Interest(s)(any entity producing, marketing, re-selling,or distributing health care goods orservices consumed by, or used on,patients.)

Research Grant(including funding
to an institution forcontractedresearch)

Speakers’BureauStock/Bonds(excluding
MutualFunds)

Consultant

Other(Identify)

I affirm that the foregoing information is complete and truthful, and I agree to notify AAOMS immediately if there are anychanges or additions to my financial relationships. During my participation in this activity, I will wholly support AAOMS’commitment to conducting CDE/CME activities with the highest integrity, scientific objectivity, and without bias. I agree that I will
not accept any honoraria, additional payments or reimbursements beyond what has been agreed upon to be paid directly by
AAOMS in relation to this educational activity.
Signature: _______________________________________________________

Page 6 of 6

Date: ____________________