Disclosure Form

*ACCME Definition of a Commercial Interest: A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients. Based on the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support, the IASLC adheres to the following:
A) All individuals in a position to control the educational content of a CME activity MUST disclose all relevant financial relationships of themselves, and/or their spouse/partner, with ACCME-defined commercial interests* prior to the CME activity.
B) Should it be determined that a conflict of interest exists, the conflict MUST be resolved prior to the CME activity.
C) Any individual who refuses to disclose these financial relationships will be disqualified from being a part of the CME activity.

D) Employees of ACCME-defined commercial interests are prohibited from having any role in the planning or implementation of CME activities related to their employer's business lines or products.

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* 1. Address:

First Name

Last Name

Email Address

Phone Number

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* 2. Credentials:

MD/DO

Other (please specify)

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* 3. Please tell us your ROLE(S) in the IASLC CME activity (ies)

Author

Planner (e g. Board or Committee Member)

Faculty/Presenter

Reviewer

Other (please specify)

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* 4. Disclosure of Financial Relationships within 12 months of date of this form (select one):

NO, neither I nor my spouse/significant other has a financial relationship(s) or interest in any amount (currently or 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.

YES, I have, or my spouse/significant other has, a financial relationship(s) or interest in any amount (currently or 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.

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* 5. If yes, indicate below your role(s) and the name(s) of the commercial interest(s) with which you have a relevant financial relationship.

Speakers Bureau

Advisory Board

Consultant

Ownership or Stock Interest

Employment

Honorarium

Financial Support from Tobacco Company(ies)

Contracted/Supported Research Grant

Royalty, Intellectual Property/Patent Holder