Financial Disclosure Form

Declaration of Speaker Financial Interests or Relationships

Important: If you do not complete and submit Sections I and II of the form below, you cannot speak at this educational activity, or participate in its planning or implementation.

Please provide the requested identification information and check the participant agreement
boxes to acknowledge that you have read this for and agree to all its provisions.

Identification Information

I. Participant Agreement: Observance of SBMT Policies

Please check each box below to acknowledge that you have read and understand each section, and will satisfy all of these obligations and responsibilities of meeting organizers, planners and/or speakers.

1. The content of educational activities designed for any form of Continuing Education (CE) credit does not, and will not promote the proprietary interests of any commercial interests. [Commercial interests are defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.]

2. Content of educational activities will be restricted to pure science (dealing with physics, chemistry and biology as opposed to the business lines or products of any commercial interest) and should not include product or company names unless essential (and subject to guidelines below).

3. Syllabus contributions, abstracts, and other required documents will be submitted as specified.

4. All recommendations involving clinical medicine must be based upon evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.

5. All scientific research referred to, reported or used in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection and analysis.

6. Unlabeled use of products: When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity, the speaker is required to disclose that the product is not labeled for the use under discussion or that the product.

7. Generic and trade names: Presentations must give a balanced view of therapeutic options. Use of generic names contributes to this impartiality. If trade names are used, those of several companies must be used, rather than only that of a single manufacturer.

8. Separation of logos from education: Commercial logos cannot be displayed on any educational materials (slides, handouts, follow-up guides). Any materials submitted with these logos will not be accepted and may jeopardize your ability to participate in any manner.

9. To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.

10. I will recuse myself from planning activity content in which I have a conflict of interest.

11. I will not accept additional compensation* from any organization due to my involvement with the SBMT.

* Note: This does not preclude a faculty member from being reimbursed for expenses by their employer. This item limits only additional funding above reimbursements.

12. I attest that my opinions are my own and are not reflecting the opinions of my employer or other association.

II. Declaration of Financial Interests or Relationships

The SBMT is committed to:

  1. ensuring balance, independence, objectivity and scientific rigor in all Continuing Medical Education programs, and
  2. presenting educational activities that promote improvements or quality in healthcare and are independent of the control of commercial interests.

As part of this commitment, the SBMT has implemented a process in which speakers and everyone else in a position to influence the content of an education activity discloses all financial relationships any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, of any amount within the last 12 months. Should it be determined that a conflict of interest exists as a result of a financial relationship and the content to be presented, this will need to be resolved prior to the activity.

Important: If you do not complete this form, whether or not you have financial relationships to declare, you will be disqualified from participating in the planning and implementation of this activity.

Affiliations and financial interests disclosed will be indicated in program and syllabus listings, and during each talk for speakers. The SBMT does not imply that such financial interests or relationships are inherently improper or that such interests or relationships would prevent the speaker from making a presentation. The intent is that any and all conflicts are identified, managed and disclosed to participants so that learners may form their own judgments about the presentation in the light of full disclosure of the facts.

The declaration applies to any real or apparent financial interest or other relationship (i.e., grants, research support, consultant fees, honoraria, etc.) that the individual may have (or have had within the last 12 months) with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. This disclosure requirement extends to interests/ financial relationships of spouses/partners. It does not apply to relationships with non-profit societies or governmental bodies (like the NIH).

Instructions

First, indicate in the Declaration Statement whether or not you (and/or your spouse/partner) have had any financial interests or relationships with any commercial interests. [Commercial interests are defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.]

Second, if you have checked the second “Declaration” box, then provide information on the types of financial relationships in the spaces provided.

The SBMT does NOT want to know how much you received. Please do not provide the amount.

Declaration Statement:

Select whichever applies to you. If you select the second option, you must include information about your relationships in the space that will be provided.