Speaker Form - 2017 Fall Symposium
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ASNM is accredited by the Accreditation Council for Continuing Medical Education (ACCME) for this educational activity. To ensure that we meet the highest standards for medical education, we adhere to the ACCME Standards for Commercial Support. These standards require disclosure of all relevant financial relationships with any commercial interest during the past 12 months for any individuals and their spouse/partner who control the content of continuing medical education.

ACCME defines financial relationships as those relationships in which an individual receives any financial benefit from a commercial interest. The financial nature of such relationships includes but is not limited to salary, royalty fees, intellectual property rights, consulting fees, honoraria, investments, and ownership interests. A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

This disclosure is not to prevent someone with financial relationships from participating but rather to provide information to evaluate potential bias. An ASNM review committee will evaluate the risk for introducing bias into the educational activity. You must complete this disclosure form before your participation can be confirmed.

Instructions: Please list all commercial interests related to this ASNM sponsored activity with the exception of nonprofit organizations, government organizations, and non-healthcare-related companies.

Your disclosure should include your spouse/partner’s financial involvement in healthcare goods.

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