Questions are relevant only to the last 12 months.

Question Title

* 1. Full name

Question Title

* 2. List below any relationships you have with:
  • A commercial company
  • Grant/Research support
  • Consultant
  • Speakers' Bureau 
  • Major Stockholder
If you have no relationships, simply list "N/A".

Question Title

* 3. Please indicate your understanding of and willingness to comply with each statement below.
  • I have disclosed all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.
  • If I have been trained or utilized by a commercial entity or its agent as a speaker (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.
Your signature on the form indicates your agreement to follow the policy, and disclosure of affiliations you have with companies that can have an impact on your planning and/or presentation. A signed Conflict of Interest/Disclosure Declaration form is required for all category 1 programs. I have read the Conflict of Interest/Disclosure Declaration Statement information and agree to abide by this policy. By typing your full legal name and date, you are submitting an electronic version of your signature. Type your full name and date (i.e. Jane Doe 5/15/18).

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