AGPA Connect 2024 Disclosure/Conflict of Interest Form

Disclosure of Financial Relationships for Continuing Education

To participate in this educational activity, all individuals who have the ability to influence and/or control the content of this accredited CE/CME activity must disclose all financial relationships with all companies — whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients — over the past 24 months.

Only disclose your own financial relationships, not those of your spouse or life partner.

You will not have the opportunity to save your answers so please complete the submission in one sitting.

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* 1. Contact Information (all information must be provided for accreditation purposes)

First Name

Last Name

Cell Phone
(For use on-site if necessary)

Email Address

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* 2. Individual’s Role(s) in this Educational Activity (check all that apply):

Planner (e.g., planning committee, course director, CE staff)

Faculty Speaker, Author, Presenter

Moderator, Panelist

Content Reviewer

Medical Writer, Editor

Other (please specify)

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* 3. Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold. We ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. (THIS WILL BE MADE KNOWN TO ATTENDEES).
Such disclosure allows the audience to better evaluate the objectivity of the information presented in sessions.

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Examples of financial relationships include employee or executive role or an owner (of a pharmaceutical or medical device manufacturer), researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, individual stocks and stock options should be disclosed, but diversified mutual funds do not need to be disclosed.

In the past 24 months, I have had financial relationships with companies as defined above.

In the past 24 months, I have not had any financial relationships with companies as defined above.

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* 4. If you declared a conflict above, you are required to provide more information. Indicate the category below and provide the name of the company and a description of the relationship in the comment box.

Salary

Royalty

Stock

Speakers Bureau

Consultant

Other

Please list ALL Company/Relationship(s) creating the conflict below:

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* 5. Enter the title of your Session (Required for any Faculty Speaker, Author, Presenter)
* If this does not apply to you, please enter N/A *

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* 6. Please check the ONE statement which accurately reflects your use of copyrighted material in your slides and/or handouts.

I have NOT included any original works of art (including photographs, cartoons, and graphic images), which are considered copyrighted material, in my presentation.

I have gained permission from the copyright owner, the person who created the work, to use or copy the image for my presentation. I can produce proof of purchase of a license to use the image from the copyright holder. NOTE: This license is usually purchased through clearinghouses like cartoonstock.com and istockphotos.com.

I have NOT gained permission from the copyright owner to use this image. I understand that my use of copyrighted images in my presentation may exceed the limits of what can be considered educational fair use under the provisions of the Copyright Act. I acknowledge that I have been informed of this, and I accept personal liability, including responsibility for any assessed fines for the possible infringement of fair use limits of the copyright, which may result from my reproduction/use of this material.

I am not presenting at Connect 2024

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* 1. Contact Information (all information must be provided for accreditation purposes)

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* 2. Individual’s Role(s) in this Educational Activity (check all that apply):

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* 4. If you declared a conflict above, you are required to provide more information. Indicate the category below and provide the name of the company and a description of the relationship in the comment box.

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* 5. Enter the title of your Session (Required for any Faculty Speaker, Author, Presenter) * If this does not apply to you, please enter N/A *

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* 6. Please check the ONE statement which accurately reflects your use of copyrighted material in your slides and/or handouts.

* 5. Enter the title of your Session (Required for any Faculty Speaker, Author, Presenter)
* If this does not apply to you, please enter N/A *