Instructions for completing this form:

1. Proposed topic – Must be a topic that is focused around heart failure management
2. Proposed venue/location – Include specific details regarding where the event is planned to occur including the physical address (e.g. Hotel meeting room, restaurant, etc.)
3. Proposed number of attendees – Indicate here the anticipated number of attendees broken out by non-Impulse Dynamics versus Impulse Dynamics personnel.
4. Proposed date of event – Indicate here the specific date desired to conduct the event. If specific date is not known, provide an estimate (e.g. July 2012)
5. Event overview – Include a general description of the event with attached documentation (exhibit request, agenda, agreement letter)
6. Description of the legitimate need for the event – Describe in substantial detail why the event is necessary.

Examples include:   Address weakness in understanding of subject area related CCM and Impulse Dynamics technology/CRM related disease states/ HF related disease states , and Education/increase awareness regarding a new product launch

7. Proposed attendees and their affiliations – List types of attendees who will be invited (Electrophysiologists, Cardiologists, Heart Failure Specialists, Fellows, Nurses, cath lab techs, etc.) and the institutions they are affiliated with.

This form and any attachments should act as stand alone documentation to drive justification of the approval of the proposed event. Submit completed form at least 6 weeks prior to the event to AVP for approval and the approved form to medical.education@impulse-dynamics.com

For questions regarding this process or for the status of where your event is in the review/approval process please contact Allison Nash at 610-858-8210.