- Please Check off all attendees
- Obtain attendee signature
- Check off no shows
- Obtain all information required for walk-ins
NephU
Attendance Roster
Otsuka Colleague:
Event Date: October 2, 2023 3:54 PM
City:
Event Location Type:
Territory:
Event Type:
State:
Location Name: Generate Sign in Sheet
Speaker Certification: I certify that I presented using company approved materials at this meeting.
| # | State License | Print First Name | Print Last Name | Degree | Practice/Affiliation | Meal Opt Out | Attested | Signature |
|---|
Attendee Sign-In:
In accordance with the PhRMA Code on Interactions with Healthcare Professionals, attendance at this educational program is limited to only Healthcare Professionals (Physicians, Practitioners, Physician Assistants, RNs, Clinical Pharmacists, Social Workers). Accordingly attendance by guests or spouses is not permitted.
This is a promotional program and no CME credits are offered. This educational Program may include the provision of a modest meal. Certain federal and/or state laws (e.g., Vermont, Minnesota as well as policies of your institution may limit your ability to accept the modest meal provided during this educational program. If you are licensed to practice in a state where meals are either prohibited and/or restricted and you accept a meal, you understand that you will be required to reimburse Otsuka for the cost of this meal.
Please note that Otsuka is required to report the value of a provided meal pursuant to applicable federal and/or state laws.
New Jersey licensed prescribers should be aware that this program may or may not be exempt as an educational program from the meal limit set forth under N.J.A.C. 13:45J.
By signing below, you represent that it is permissible for you to accept this meal under these laws or policies or you have indicated your decision to opt out of receiving a meal. (edited)
NephU
Attendance Roster
Attendee Sign-In:
In accordance with the PhRMA Code on Interactions with Healthcare Professionals, attendance at this educational program is limited to only Healthcare Professionals (Physicians, Practitioners, Physician Assistants, RNs, Clinical Pharmacists, Social Workers). Accordingly attendance by guests or spouses is not permitted.
This is a promotional program and no CME credits are offered. This educational Program may include the provision of a modest meal. Certain federal and/or state laws (e.g., Vermont, Minnesota as well as policies of your institution may limit your ability to accept the modest meal provided during this educational program. If you are licensed to practice in a state where meals are either prohibited and/or restricted and you accept a meal, you understand that you will be required to reimburse Otsuka for the cost of this meal.
Please note that Otsuka is required to report the value of a provided meal pursuant to applicable federal and/or state laws.
New Jersey licensed prescribers should be aware that this program may or may not be exempt as an educational program from the meal limit set forth under N.J.A.C. 13:45J.
By signing below, you represent that it is permissible for you to accept this meal under these laws or policies or you have indicated your decision to opt out of receiving a meal. (edited)
Pre-Registered:
Event Number:
Event Date: October 2, 2023 3:54 PM
| Print First Name | Print Last Name | State License | NPI | Place of Business(Hospital, Affiliation, Private Practice) | Address | Professional Type (e.g., MD, DO, RN, LPN, MA, PharmD, PsyD, Lisc. State Worker, Non-HCP, Staff) | Specialty |
|---|
NephU
Attendance Roster
Attendee Sign-In:
In accordance with the PhRMA Code on Interactions with Healthcare Professionals, attendance at this educational program is limited to only Healthcare Professionals (Physicians, Practitioners, Physician Assistants, RNs, Clinical Pharmacists, Social Workers). Accordingly attendance by guests or spouses is not permitted.
This is a promotional program and no CME credits are offered. This educational Program may include the provision of a modest meal. Certain federal and/or state laws (e.g., Vermont, Minnesota as well as policies of your institution may limit your ability to accept the modest meal provided during this educational program. If you are licensed to practice in a state where meals are either prohibited and/or restricted and you accept a meal, you understand that you will be required to reimburse Otsuka for the cost of this meal.
Please note that Otsuka is required to report the value of a provided meal pursuant to applicable federal and/or state laws.
New Jersey licensed prescribers should be aware that this program may or may not be exempt as an educational program from the meal limit set forth under N.J.A.C. 13:45J.
By signing below, you represent that it is permissible for you to accept this meal under these laws or policies or you have indicated your decision to opt out of receiving a meal. (edited)
Walk-Ins:
Event Number:
Event Date: October 2, 2023 3:54 PM
| Print First Name | Print Last Name | State License | NPI | Place of Business(Hospital, Affiliation, Private Practice) | Business Address | Professional Type (e.g., MD, DO, RN, LPN, MA, PharmD, PsyD, Lisc. State Worker, Non-HCP, Staff) | specialty | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|
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NephU
Attendance Roster
Attendee Sign-In:
In accordance with the PhRMA Code on Interactions with Healthcare Professionals, attendance at this educational program is limited to only Healthcare Professionals (Physicians, Practitioners, Physician Assistants, RNs, Clinical Pharmacists, Social Workers). Accordingly attendance by guests or spouses is not permitted.
This is a promotional program and no CME credits are offered. This educational Program may include the provision of a modest meal. Certain federal and/or state laws (e.g., Vermont, Minnesota as well as policies of your institution may limit your ability to accept the modest meal provided during this educational program. If you are licensed to practice in a state where meals are either prohibited and/or restricted and you accept a meal, you understand that you will be required to reimburse Otsuka for the cost of this meal.
Please note that Otsuka is required to report the value of a provided meal pursuant to applicable federal and/or state laws.
New Jersey licensed prescribers should be aware that this program may or may not be exempt as an educational program from the meal limit set forth under N.J.A.C. 13:45J.
By signing below, you represent that it is permissible for you to accept this meal under these laws or policies or you have indicated your decision to opt out of receiving a meal. (edited)
| # of Presenters | # of HCP Attendees (Not including Presenter) | # of Non-HCP Attendees | # of Employee/Associates | Total # of Attendees: (including yourself, colleagues, speaker, and All other attendees) | ||
|---|---|---|---|---|---|---|
Client Personnel: By signing this document, I am verifying all information is accurate and complete and the above HCPs attended this meeting
| Print First Name | Print Last Name | Address | City | State | Zip | Phone | Meal Opt-Out | Signature |
|---|---|---|---|---|---|---|---|---|
CERTIFICATION
To the best of my knowledge, I confirm that this program was conducted in accordance with Otsuka America Pharmaceutical Development & Commercialization, Inc. (OPDC) policies, except as indicated by any \"No\" response below. I have explained each \"No\" response in the comments section below. (Please ensure all boxes are checked prior to submitting Sign-In Sheet)
| I verify that the program was monitored live by company personnel. | Yes | No | ||
| I verify that all attendees at this program were appropriate (no inappropriate specialties, spouses or uninvited guests). | Yes | No | ||
| I verify that only approved meeting materials were presented, shown and/or distributed to Program attendees. | Yes | No | ||
| I verify that the Speaker and/or company employees appropriately handled unsolicited off-label questions. | Yes | No | ||
| I verify that the Speakers presentation was fair and balanced. | Yes | No | ||
| This attendance roster represents an accurate and complete list of all Health Care Professionals and any other individuals who attended the event. | Yes | No | ||
| I have submitted an accurate list of all Health Care Professionals/Customers who attended the event. | Yes | No |
Comments (Required for any "No" response above):
Otsuka Colleague Signature & Date:
Remote Attendee Sign In
Registration Number:
Date: October 2, 2023 3:54 PM
Speaker(s):
Attendee Check-In for this event will be activated on:
No Time Provided
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