DISCLOSURE - 20th Annual Academic Surgical Congress

Individual’s role(s) in this educational activity: (check all that apply)(Required)

Planning Committee Member

Presenter/Author

Content Reviewer

Committee Member

Staff

Select Committee(s)

Please select all that apply

Directions: Type information directly into the space provided, or type an ‘X’ in the appropriate box to indicate your response. Do not attach any additional materials.

Name and Credentials(Required)

Organization/Employer:(Required)

Current Position/Title:

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Disclosures of Financial Relationships with Ineligible Companies

Employees or owners of an ineligible company may not influence the planning, delivery, or evaluation of an educational activity except in very limited circumstances.
An Ineligible company, as defined by ACCME, is any company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients, or an entity owned or controlled by a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Non-healthcare-related companies, healthcare facilities, and group medical practices are not considered ineligible companies.

1. Are you employed by, or do you have ownership in, any ineligible company?(Required)

Yes

Company name:

All individuals in a position to influence content must disclose ALL financial relationships with ineligible companies occurring within the past 24 months.
Please disclose financial relationships of any dollar amount. Examples of different types of financial relationships may include honoraria, consulting fees, speaking fees, salary, ownership interest, royalties, grants, holding a patent on equipment, intellectual property rights, gifts, and any other type of compensation.

2. Over the past 24 months, have you had a financial relationship with an ineligible company?(Required)

Yes

List

Name of Ineligible Company

Type of Relationship(s)

Click ‘+’ to add company

If it is determined that your financial relationship(s) with ineligible company(ies) are relevant, you will be contacted for assistance in mitigating the relationship. All relevant financial relationships with ineligible companies must be mitigated for planners, presenters, authors, content reviewers, and other individuals in a position to influence content prior to the planning of the educational activity.

Scientific Research Area (check all that apply)

Basic Science/Translational

Clinical Outcomes/Health Services

Education

Clinical Area (check all that apply)

Electronic Signature:

Electronic Signature(Required)

Checking this box serves as the electronic signature of the individual completing this form and attests to the accuracy of the information given above.

Name(Required)

First Last

Date(Required)

mm/dd/yyyy

This field is for validation purposes and should be left unchanged.

Disclosures of Financial Relationships with Ineligible Companies

Electronic Signature:

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