ASCIP 2022 Disclosure of Financial and Non-Financial Relationships NOTE: This form may be incompatible with older Internet Explorer browsers. We recommend using Chrome for best results. Please contact us if you require additional support. Please enable JavaScript in your browser to complete this form.Name *FirstLastPlease enter your first and last name (including your professional credentials), as indicated in the boxesEmail *EmailConfirm EmailPhoneActivity Title * Role(s): Check All that Apply *PlannerCore FacultyReviewerCourse DirectorModeratorTeacherAuthorOtherOther (Please Describe)Abstract Title *If more than one presentation, please separate each title with a semicolon. If you are not presenting faculty please enter NAPART I: DISCLOSURE OF FINANCIAL AND NON-FINANCIAL RELATIONSHIPSPlease list any non-financial conflict of interest. Examples would be Speaking/teaching, member of an association, membership on advisory or review panels, chairing a related voluntary committee, board member etc. (If you have no non-financial conflicts of interest, please answer N/A.) *CRITERIA FOR DISCLOSURE OF FINANCIAL RELATIONSHIPS WITH COMMERCIAL INTEREST 1. Anyone who can affect the content of an accredited educational activity is required to disclose financial relationships they may have with commercial interests (i.e., any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). 2. You are to disclose financial relationships in any amount that has been received over the past 12 months ONLY from the date of submission of this form. 3. Financial relationships with government agencies (e.g., the NIH) and organizations that do not fit the above definition of a commercial interest do not have to be disclosed. 4. Honoraria or consulting funds received from a CME/CE provider, even though those funds may have been provided to that CME/CE provider through an educational grant from a commercial interest, do not have to be disclosed. 5. If you are a principal investigator for a drug study, you must report that research relationship below under "Contracted Research" even if those funds came to an institution. 6. If your spouse or life partner has a relevant financial relationship with an applicable commercial interest (e.g., is employed as the VP-Marketing), or provides marketing advice to an applicable commercial interest as a consultant, you must include that disclosure in the table below. 7. In accordance with requirements, failure to provide disclosure information in a timely manner will result in the disqualification of the potential planner, course director, moderator, faculty, presenter, author or reviewer from this activity. Within the past 12 months, have you and/or your spouse/ life partner received support from, or had a relationship with, a commercial interest? *NoYes, within the past 12 months from today’s date, I or my spouse/life partner have/has had a relevant financial relationship with a commercial interest as listed below.Salary (employed relationship) *Name of Applicable Commercial Interest. Reply N/A if this doesn't apply.Royalty and/or Receipt of Intellectual Property Rights/Patent Holder *Name of Applicable Commercial Interest. Reply N/A if this doesn't apply.Consulting Fee *Name of Applicable Commercial Interest. Reply N/A if this doesn't apply.Speakers Bureau *Name of Applicable Commercial Interest. Reply N/A if this doesn't apply.Fees for Non-CME/CE Services Received Directly from a Commercial Interest or its AgentName of Applicable Commercial InterestContracted Research *Only include research funds received directly from industry; grants to your institution are NOT reportable. If you are a principal investigator, you must report a financial relationship even if those funds came to the institution for which you work. Reply N/A if this doesn't apply.Ownership Interest *Include stocks, stock options, or other ownership interest excluding diversified mutual funds. Reply N/A if this doesn't apply.OtherPlease describeIf you reported relationships in the questions above, will any of these relationships impact your ability to present an unbiased presentation? *YesNoPlease explain *PART II - Unlabeled/Unapproved DrugsDo you intend to reference off-label/unapproved uses of drugs or products in the educational activity? *YesNoNames of drugs or products you will reference: *PART III: Attestation of CME Value Statements Please indicate your understanding of and willingness to comply with each statement below. If any statements do not apply to your participation in this activity, select "N/A." If you require clarification of these statements or have questions regarding your ability to comply, please email our education office (theresa@lutinemanagement.com) immediately I have disclosed all relevant financial relationships and I will disclose this information to learners *AgreeDisagreeThe content and/or presentation I am involved in will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be balanced, evidence-based and commercially unbiased. *AgreeDisagreeN/AI have not and will not accept any honoraria, additional payments or reimbursements directly from a commercial interest for my participation in this activity. *AgreeDisagreeN/AI understand that the CME/CE provider may need to review my presentation and/or content prior to the activity, and I will provide content and resources in advance as requested *AgreeDisagreeN/AIf I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All reference to scientific research will conform to the generally accepted standard of experimental design, data collection and analysis. *AgreeDisagreeN/AIf I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company. *AgreeDisagreeN/AIf I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA. *AgreeDisagreeN/AIf I am presenting research funded by a commercial interest, the information presented will be based on generally accepted scientific principals and methods and will not promote the commercial interest of the funding company. *AgreeDisagreeN/ATyping my name in the space above indicates that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided on page 1 of this form will be shared with learners prior to their engagement in this CME activity. *Date *MessageSubmit
