* 1. CONTACT INFORMATION: Enter your complete contact information below. Please include your degree(s)/credentials.

* 2. Please indicate your area of expertise below:

* 3. Which categories are you interested in reviewing?  You may pick multiple categories.

* 4. Disclosure of Relationships with Commercial Interests

Throughout its educational and scientific programming, the AGS strives to insure balance, independence, objectivity, and scientific rigor in all activities for which it sponsors credit. A conflict of interest exists when an individual or their spouse/partner has a financial relationship with a commercial interest. These relationships are defined as financial relationships in any amount occurring within the past 12 months with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. All faculty, authors, members of planning committees, reviewers and staff participating in any AGS educational activity are therefore expected to disclose all financial relationships.

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research which includes research funding where the institution gets the grant and manages the funds and the person is the principal or named investigator on the grant), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

You must complete this Proposal Reviewer Disclosure Form even if you have no relationships with commercial interests to report. Failure to complete the form will mean that you cannot participate in this activity.

Do you or your spouse/partner have any relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients?

* 5. Please list the manufacturer(s) or provider(s) the product/service, and you or your spouse/partner's relationship (e.g. paid consultant, employee, grant support, speakers bureau, significant shareholder, etc.):

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