Financial Relationship Disclosure Form Name* First Last Email* Meeting Disclosing For:*Required AgreementsPlace a check in the box by each of the statements below to indicate your understanding and willingness to comply with each of the following statements.Agree* I have disclosed all relevant financial relationships to the ASMBS and will disclose any subsequent relationships (if applicable) to learners verbally and in print in any CME activities. I will not accept any honorarium/payment/reimbursement beyond what has been agreed upon directly with ASMBS for any ASMBS educational programs. All scientific research to support a patient care recommendation will confirm to generally accepted standards of experimental design, data collection and analysis. I will base my contributions on the best scientific evidence available regarding this content. My contributions will give a balanced view of therapeutic options and be unbiased. If any portion of my presentation slides or contributed data is not original work, I will obtain necessary copyright permission (as applicable). My contributions will not promote the products or services of any commercial interest related to this content. I will not use trade names of healthcare products or services in any CME activity presentations. You must agree to all the above statments to submit this form.DisclosureAre you an employee or do you receive a salary from a commercial interest?*YesNoFinancial RelationshipsList companies with which you, your spouse and/or your partner currently have had financial relationship(s) within the past 12 months.Do you have financial relationships to disclose?*YesNoCompany 1 NameWhat was received from Company 1?What was your role with Company 1? Add another compnay… Company 2 NameWhat was received from Company 2?What was your role with Company 2? Add another company… Company 3 NameWhat was received from Company 3?What was your role with Company 3? Add another company… Company 4 NameWhat was received from Company 4?What was your role with Company 4? Add another company… Company 5 NameWhat was received from Company 5?What was your role with Company 5?Additional InformationBased on the statement above, do you have additional disclosure information to input? If so, please enter it in this space.By clicking “submit”, you attest to the fact that you have read, and are in agreement with, Part 4 of the ASMBS CME Policy on Disclosure as provided here.You must agree to all the Required Agreements above and complete all required fields to submit this form.All presentations are required to incorporate the PPT slide available for download below. Please feel free to use this sample.
