Disclosure of Financial Relationships Form

First name: *

Last name: *

ACS User ID Number (if readily available):

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

Email address: *

Name of Activity: *

Your Role: *

Your Role: Other...

Date of Activity: *

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.

Disclosures *

I am an owner or employee of an ineligible company. I am to be excluded from controlling content or participating as faculty in accredited education unless the planning chair determines that I meet an ACCME exception on page 2 of the Mitigation Section. For more information: ACCME Standard 3

I am a stockholder of a privately held ineligible company (not through a mutual fund or pension plan). I am to be excluded from controlling content or participating as faculty in accredited education unless the planning chair determines that I meet an ACCME exception on page 2 of the Mitigation Section. For more information: ACCME Standard 3

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.

On the table below, list the names of companies that you have a financial relationship with currently or have had in the last 24 months.
Specify your role (i.e., consultant, board member, etc.)
Explain what you received (i.e., salary, honorarium etc.).
If equity was received, designate if it is public or privately traded (only if applicable)

Company name(s) *

What I received *

For what role? *

If equity was received, designate if it is public or privately traded company (only if applicable)

If a financial relationship is noted above, a designated official must complete page 3-4 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.

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

I agree that I will not directly accept honoraria, travel expenses, in-kind contributions, or any other support from commercial companies/ineligible companies in connection with this activity (Support provided with a letter of agreement may be permissible). *

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: *

Date: *

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