Disclosure of Financial Relationships Form

In accordance with ACCME regulations (ACCME Standard 3), the American College of Surgeons must ensure that anyone who is able to control the content of the activity has disclosed all financial relationships with any ineligible companies in the 24 months prior to their involvement in the educational activity.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME system (ineligible companies) are those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.

Financial Relationships: Financial relationships are relevant if the following three conditions are met for the individual who will control content of the education: 1) a financial relationship, in any amount, exists between the person in control of content and an ineligible company; 2) the financial relationship existed in the last 24 months; 3) the content of the education is related to the products of an ineligible company with whom the person 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. This form must be updated whenever circumstances require. As relevant, all disclosure information for speakers must be revealed by a slide at the beginning of the presentation.

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

First name: *

Last name: *

ACS User ID Number (if readily available):

Credentials (MD, DO, PA, RN, etc.):

Email address: *

Activity title: *

Date of the activity: *

What is your role in this activity? *

What is your role in this activity? Other...

Disclosure *

In the past 24 months, have you 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?

I DO NOT have personal financial relationships with any ineligible companies as defined above.

I DO have financial relationship(s) with ineligible companies as defined above.

List the names of companies that you have a financial relationship with currently or have had in the last 24 months.
Explain what you 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.

Company name(s) *

What I received *

For what role? *

Are the products or services of any of the companies relevant in any way to your presentation? *

If a financial relationship is noted above, a designated official must complete page 2 after discussing ways to mitigate the conflict of interest with you. As relevant, this mitigation and the Mitigation Section must be completed prior to the start of the planning process.

I agree that I will not accept honoraria, travel expenses, in-kind contributions, or any other support from commercial companies/ineligible companies in connection with this activity. *

I agree

If I am discussing any off-label product use, I will disclose that the FDA does not currently approve the use or indication in question for labeling or advertising. *

I agree

If any of the information reported above changes, I will notify AACS immediately and update this form accordingly. *

I agree

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.

Name: *

Leave this field blank

You are here