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.
II. Declaration of Financial Interests or Relationships
The SBMT is committed to:
ensuring balance, independence, objectivity and scientific rigor in all Continuing Medical Education programs, and
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:
Financial Relationships
C. Other types of financial interests:
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