In accordance with ACCME regulations, the accredited provider, the American College of Surgeons, must ensure that anyone who is in a position to control the content of the educational activity has disclosed all financial relationships with any commercial interests (termed by the ACCME as “ineligible companies”, defined below) in the last 24 months prior to their involvement of the educational activity.

  • Ineligible Company: Defined by the ACCME as any company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
  • Financial Relationships: Relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefits. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. The relationship should include the person involved in the CME activity and their spouse or partner.
  • Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

All CME Planners and Speakers /Moderators/Discussants/Authors/Editors involved in the development and/or presentation of CME content must complete this form. If applicable, the first author is responsible for collecting and submitting disclosure information on behalf of all other authors/contributors. The form must be updated whenever circumstances require it. In addition, all affirmative disclosures for speakers must be revealed by a slide at the beginning of the presentation.

Failure or refusal to disclose or the inability to manage the identified conflict will result in the withdrawal of the invitation to participate.

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In the past 24 months, have you or your spouse/partner had a financial relationship with any company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients?
  • List the names of companies that you (or your Spouse/Partner) have a financial relationship with currently or have had in the last 24 months.
  • Explain what you (or your Spouse/Partner) received (i.e., salary, honorarium etc.).
  • Specify your role (i.e., consultant, board member, etc.)
  • As a result of your disclosure of a financial relationship with an ineligible company, you will be contacted by a designated official to discuss the possible conflict of interest and determine the most appropriate management strategy to ensure unbiased CME content.
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By signing or typing my name above, I certify that I have identified and disclosed all financial relationships with any ineligible companies in the last 24 months and that all information provided herein is true and correct.

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