test test other paged form: ACCME Disclosures Step 1 of 5 20% As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), AHNS must insure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational activities. We are required to identify and resolve all potential conflicts of interest with any individual in a position to influence and/or control the content of CME activities. A potential conflict of interest is considered to exist if the individual and/or their spouse or partner has received financial benefit in any amount from a commercial interest involved in the activity within the past 12 months. A commercial interest is defined as any proprietary entity producing health care goods or services, with the exception of non-profit, government organizations or providers of clinical service directly to patients. All disclosure information will be reviewed to determine if a potential conflict of interest exists. Additional information may be requested to make this determination. Any changes in the disclosure information prior to the presentation should be forwarded to the AHNS office.Name* First Last Degree(s) InstitutionEmail* Cell Phone*Please indicate if you have any relationships with industry to disclose. If you answer "Yes" to the below, we will need to collect the company information on the next step.*Yes, I or my spouse have at present or have had within the last 12 months a relevant financial relationship with a commercial interest.No, I or my spouse have NOT had within the last 12 months a relevant financial relationship with a commercial interest. First RelationshipCompany*What was Received?*SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above*What was your Role with the Company*EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MembersOtherPlease explain your choice of "other" above*Is this relationship relevant to your participation*YesNoYou answered YES to the question above, so now we need to resolve any potential conflict of interest.*The financial relationship does not relate to the content of my educational assignment/presentation.I will be using best available published evidence to support my presentation.I am changing my relationship with the commercial interest.All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysisI suggest that my presentation be peer reviewed prior to the activity date.OtherUnsurePlease fully explain your choice above.*Add a second disclosure? Yes Second RelationshipCompany*What was Received?*SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above*What was your Role with the Company*EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MembersOtherPlease explain your choice of "other" above*Is this relationship relevant to your participation*YesNoYou answered YES to the question above, so now we need to resolve any potential conflict of interest.*The financial relationship does not relate to the content of my educational assignment/presentation.I will be using best available published evidence to support my presentation.I am changing my relationship with the commercial interest.All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysisI suggest that my presentation be peer reviewed prior to the activity date.OtherUnsurePlease fully explain your choice above.*Add a third disclosure? Yes Third RelationshipCompany*What was Received?*SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above*What was your Role with the Company*EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MembersOtherPlease explain your choice of "other" above*Is this relationship relevant to your participation*YesNoYou answered YES to the question above, so now we need to resolve any potential conflict of interest.*The financial relationship does not relate to the content of my educational assignment/presentation.I will be using best available published evidence to support my presentation.I am changing my relationship with the commercial interest.All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysisI suggest that my presentation be peer reviewed prior to the activity date.OtherUnsurePlease fully explain your choice above.* Confirmation* By checking this box I certify the preceding information is true and correct. I further agree that I will communicate any changes in my industry relationships to the AHNS as soon as possible. CommentsThis field is for validation purposes and should be left unchanged. Share:FacebookTwitterLinkedIn