2025 FDS Disclosure Statement and Abstract Catalog Form

Speaker Disclosure Statement

If you are presenting more than once, you only need to complete one disclosure.

Speaker Disclosure Statement

The Medical Educational Council of Pensacola (MECOP) requires that all speakers, faculty members and planning committee members complete a Disclosure Statement so that relevant relationships with commercial interests are disclosed to the provider. All relevant relationships of the speaker/committee member and their spouse/partner must be listed below.

Please note that MECOP defines “relevant” as any relationship/dollar amount in the past 12 months. A commercial interest is any entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients.

Each speaker is required to complete this form.

Conference Name: 2025 APGO Martin L. Stone, MD, Faculty Development Seminar
Date: January 11-14, 2025

Commercial Interests:*

I DO NOT have a relevant relationship with any commercial interest(s), and neither does my spouse/partner.
I DO have a relevant relationship with a commercial interest(s). Please specify relationships below:

Potential Conflicts of Interest (type NONE if no conflicts)*

Do you have any potential conflicts of interest to disclose? If so, please list them here including Company Name, Relationship and whether it is self/spouse/partner. If you have nothing to disclose, type NONE in the text box.

Discussion*

I WILL NOT be discussing off label/investigational use of a commercial product or device.
I WILL be discussing off label/investigational use of a commercial product or device.

Signature*

By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this disclosure statement.

MECOP does not imply that such relationships will prevent the speaker/committee member from making an unbiased presentation/decision. However, it is imperative that such relationships be identified so that MECOP can determine work to resolve any conflict(s) of interest, should one arise.

APGO Abstract Catalog Form (to be completed once per presentation by the primary author)

Primary Author First Name

Primary Author Last Name

Primary Author Degrees (MD, DO, etc)

Primary Author Email

Second Author First Name

Second Author Last Name

Second Author Degrees (MD, DO, etc)

Third Author First Name

Third Author Last Name

Third Author Degrees (MD, DO, etc)

Workshop Title

Objective/ Background

Methods

Results

Conclusion/ Discussion

Check fields that apply. (To ensure proper search functionality, check only relevant boxes or a maximum of 2 in each category.)

Related APGO Objective (if applicable)

Related APGO Publications/Modules

Intended Audience

Student
Resident
Faculty
Clerkship Director
Clerkship Coordinator
Osteopathic Faculty
Residency Director
Residency Coordinator

Competencies Addressed

Patient Care
Medical Knowledge
Professionalism
Systems-Based Practice & Improvement
Interpersonal & Communication Skills
Practice-Based Learning & Improvement

Educational Continuum

GME
CME
UME

Educational Focus

Educational Focus (Other)

Clinical Focus

*Unless an abstract specifically falls into any of these clinical focus categories, please leave this section blank*

Keywords

The following is a list of possible keywords to use when categorizing abstracts. We recommend you select at least six keywords from this list or your own to help users locate abstracts that fit their search terms.

Keywords (Other)