Financial Disclosures for all individuals who can influence or control content of IASLC activities:

Purpose:
The Accreditation Council for Continuing Medical Education (ACCME) requires CME providers to identify and resolve all potential conflicts of interest of planners and presenters prior to a CME activity (i.e., all individuals in a position to control the content). When financial relevant relationships are disclosed, the potential conflict must be resolved. Relevant financial relationships identified on the disclosure form (including the absence of such relationships) must be conveyed to the audience prior to the activity.

Definitions: "Relevant financial relationships" are those in which an individual (including spouse/partner) has both:

1. a personal financial relationship (any amount) with a commercial interest (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) in the past 12 months, whether the relationship has now ended or is currently active.

2. Control in planning or presenting educational content addressing specific products of the commercial interest (not simply a whole class of products as a group).

(No disclosures needed for relationships with non-profits, government units, or entities not producing health care goods or services.)

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* 1. Address

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* 2. Credentials:

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* 3. Please indicate the Abstract (s) YOU have authored:

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* 4. Please select your role(s) in the educational activity:

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* 5. Disclosure. Regarding my role in the CME activity listed above, currently or in the past 12 months (select one):

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* 6. If you have selected the box: YES I have a financial relationship(s), please select the role(s) below that apply; otherwise, please move to Question 7.

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* 7. If you have selected the box: YES I have a financial relationship(s), and selected the role(s) above please gives us the name of the commercial interest  and the nature of the relationship you have with each commercial interest :

Balance in content: Planners and Presenters et. al. should be aware that:
  • Presentations, individually or in combination during the activity, must give a balanced view of the therapeutic options.
  • Generic names of products contribute to impartiality. If trade names are used, those of several companies should be used.
  • For FDA-regulated products, unapproved uses (i.e., "off-label" uses)must be identified as such.
  • If information is to be presented that is not established medical practice, the information must be identified as such.
DECLARATION
  1. I have disclosed to IASLC all relevant financial relationships. If I am a presenter for a lecture/didactic session, I will also disclose these relationships to learners (verbally, through a slide, etc.), so they may form their own opinions as to possible bias.
  2. If I am a committee member, I have disclosed to the Chair.
  3. I understand that incomplete, inaccurate or refusal to disclose will preclude me from participating in the development/delivery of content of this CME activity.
  4. I am aware that the IASLC will disclose this information to learners
  5. and/or the planning committee chair through additional means and, where evaluation forms are used, ask participants to indicate their opinions regarding possible bias.
  6. Should I be involved in CME topic or content development and/or presentation of information, my involvement will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest.
  7. The content with which I am involved, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.
  8. I am aware that IASLC has implemented a mechanism for identifying and resolving conflicts of interest. As a result, I may be required to recuse myself from content planning/design/presentation on specific topics etc.
  9. I will not accept honoraria, payments or reimbursements related to IASLC CME activities, unless agreed upon directly with IASLC.
  10. I understand that IASLC may request to review my presentation and/or content prior to the activity. I will provide educational content and resources in advance if requested.
  11. I understand that participants may be asked to evaluate whether my contribution to a CME \ activity is educational, and not promotional, in nature.
  12. If 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.
  13. If I am providing patient care recommendations, all supporting scientific research I use, report or to which I refer, will conform to the generally accepted standards of experimental design, data collection and analysis.
  14. If I am discussing specific healthcare products or services, I will use generic names when applicable.
  15. If 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 for labeling or advertising.
  16. If I have been trained or used as a speaker by a commercial entity or its agent (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.
  17. If I am presenting/providing content on research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods and will not promote the commercial interest of the funding company.
  18. In consideration of HIPAA requirements, I understand and agree to take reasonable steps to protect confidential patient information by using only blinded and / or de-identified patient information. Where applicable, only the minimum information necessary to conduct CME education will be used and disclosed. 
  19. It is understood that further disclosure of patient health information outside of the CME activity is not permitted.
Disclosure of Tobacco Related Remuneration:

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* 8. I have or my immediate family member in the past 10 years received research funding, honoraria, gifts etc. from entity funded directly by an entity having an investment, licensing or other commercial interest in tobacco or tobacco products.

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* 9. If Yes please complete below:

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* 10. I have or my immediate family member in the past 10 years received trips, travel, gifts, or other in-kind payments not directly related to research activities, research funding or other funding in an entity having an investment, licensing, or other commercial interest in tobacco or tobacco products.

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* 11. If Yes please complete below:

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* 12.

ETHICAL REASEARCH STANDARDS:

As the senior author, I certify that any prospective research reported has been conducted in accordance with appropriate ethical standards such as the Declaration of Helsinki or the United States "Common Rule".

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* 13. * If any " Current Relationship" is checked on the boxes above, the "RESOLUTION of Conflict of Interest" section below must also be completed. Additional information may be requested.

Resolution: To assure independence and balance content, current conflicts of interest were resolved by the following process ( select one):

NOTE: After you complete this disclosure form, It is your responsibility to inform IASLC if the status of your financial relationship changes prior to your presentation.

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* 14. Electronic Signature (you must agree and check all).

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* 15. Date

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Thank you for your participation!

Questions about this form, please contact Carlos Ferreira via email at Carlos.Ferreira@iaslc.org or by phone at 720-598-1945

International Association for the Study of Lung Cancer
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