COI Disclosure form ~ ANS 55th Annual Spring meeting
April 24-26, 2020 Atlanta, GA

In order to complete Part I of the ANS Abstract submission process, as the Primary author, please complete the following Conflict of Interest/Disclosure form as it relates to you as the primary author. If you are not the presenter, you will be required to complete a COI/DISCLOSURE for the presenter as well. Co-authors (non speaking roles) are NO LONGER REQUIRED to fill out a COI/DISCLOSURE form.

You Must Indicate ONE of the Following when Submitting Your Abstract.
ORAL (will be considered for ORAL presentation only, a POSTER slot will not be offered as an alternative)
POSTER
EITHER (selecting this category does not lessen your chances of being selected for an ORAL presentation)

The preferred method of presentation (ORAL or POSTER) should be noted. If you select EITHER, the ANS Scientific Program Committee will make the final determination as to where to place your abstract. The same submission rules apply for both POSTER and ORAL submissions.  In order to be considered for an award, the abstract must first be selected by the Scientific Program Committee as an ORAL presentation, (you may submit as ORAL or EITHER).

FROM THE SUBMISSION FORM RE IRB:
Approval of your studies/research must be acquired before the data is collected. Any data collected prior to IRB approval is in violation of IRB rules. IRB APPROVAL MUST BE DISCLOSED AT THE TIME OF SUBMISSION. You must enter the IRB/IACUC number and/or the name of the entity providing approval on the template provided for your abstract submission. Simply entering YES is in not acceptable. NO EXCEPTIONS. If the study has qualified as exempt from an IRB formal review, authors may state EXEMPT on the abstract submission form.

OUT of USA SUBMISSIONS:
APPROVAL MUST BE OBTAINED & NOTED from the appropriate ethical entity at the time of submission.
*Failure to comply will result in disqualification of your abstract

Upon successful completion of the COI/Disclosure form, you will be automatically directed to the Abstract submission form. Your abstract submission will be sent electronically to the ANS Administrative Office. You will receive a confirmation email once your abstract has been received.

THANK YOU FOR YOUR COMPLIANCE!
Kristen Bordignon, ANS Executive Administrator
Ashley Eikenberry, ANS Co-Administrator
FROM THE AMERICAN COLLEGE OF SURGEONS, THE ACCREDITED PROVIDER:

In accordance with ACCME regulations, the American College of Surgeons must ensure that anyone who is in a position to control the content of the education activity has disclosed all financial relationships with any commercial interests (see below for definitions):

Commercial Interest: The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services used on or consumed by patients. Providers of clinical services directly to patients are NOT included in this definition.

Financial Relationships: 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), 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.

Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.
ACS is also required, through our joint providership partners, to manage any reported conflict and eliminate the potential for bias during the activity. All program committee members and speakers were contacted and the conflicts listed below have been managed to our satisfaction. However, if you perceive a bias during a session, please report the circumstances on the session evaluation form.

Please note we have advised the speakers that it is their responsibility to disclose at the start of their presentation if they will be describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage.

The requirement for disclosure is not intended to imply any impropriety of such relationships, but simply to identify such relationships through full disclosure and to allow the audience to form its own judgments regarding the presentation.

Failure or refusal to disclose or the inability to manage the identified conflict will result in the withdrawal of the invitation to participate.

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* 1. Please complete the following:

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* 2. Title of Abstract: (must match EXACTLY with your Abstract submission title) TRADE NAMES ARE NOT PERMITTED WITHIN THE TITLE when a GENERIC TERM is available.

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* 3. What is your role in this CME Activity: (Check all that apply)

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* 4. I disclose the following:

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* 5. I have disclosed to the ANS all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.

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* 6. I agree that I will not accept honoraria, travel expenses, in-kind contributions, or any other support from commercial companies in connection with this activity.

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* 7. If any of the information reported above changes, I will notify ACS immediately and update this form accordingly.

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* 8. By checking this box I confirm this abstract is exclusive to ANS and I will NOT submit it to any other participating COSM society, this includes AOS. I understand that a duplicate submission to ANS & AOS will disqualify my abstract from both Societies.

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* 9. By signing or typing my name below, as the PRIMARY AUTHOR, I certify that I have identified and disclosed all financial relationships with any commercial interests and that all information provided herein is true and correct.

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* 10. I am the primary author and presenter.

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