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  1. Please Check off all attendees
  2. Obtain attendee signature
  3. Check off no shows
  4. 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)

SRD:

Confidential & Proprietary

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

SRD:

Confidential & Proprietary

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
Signature:

SRD:

Confidential & Proprietary

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:

SRD:

Confidential & Proprietary

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

Scan the code below with your mobile camera.

SRD:

Confidential & Proprietary

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NephU is supported by Otsuka Pharmaceutical Development & Commercialization, Inc. (OPDC) and Otsuka America Pharmaceutical, Inc. (OAPI) - committed supporters of the Kidney Health Community. The information provided through NephU is intended for the educational benefit of health care professionals and others who support care for those with kidney disease and other related conditions. It is not intended as, nor is it a substitute for, medical care, advice, or professional diagnosis. Health care professionals should use their independent medical judgement when reviewing NephU’s educational resources. Users seeking medical advice should consult with a health care professional. No CME or CEU credits are available through any of the resources provided by NephU. Some of the contributors may be paid consultants of OPDC and/or OAPI.
May 2020 MRC2.CORP.X.04767
©2023 Otsuka Pharmaceutical Development & Commercialization, Inc. All rights reserved.
    logo
  • Home
  • About
    • About NephU
    • Meet The Team
    • Supporting Organizations
    • Community Advisors
    • Contact Us
    • Diversity, Equity, & Inclusion
  • Events
    • Presentation Request
    • Upcoming Events
  • Resource Center
    • Rare Kidney Diseases (PKD, IgAN, & Others)
    • Kidney Disease & Mental Health
    • Kidney Disease & Comorbid Conditions
    • Transplantation & Dialysis
    • NephU Nutrition & The NephChefR
    • Radiology Toolkit
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    • Infographics
    • Podcasts
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  • Request A Presentation
  • ADPKD Simulator
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