For CME accredited Contributors including, but not limited to Leadership, Program Chairs, Program Committee Members, Moderators, Faculty, Speakers, Reviewers, Teachers, Authors, Medical Writers, and Staff.

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* 1. Full Name

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* 2. Do you, your spouse, partner have any relevant financial relationships with a commercial interest related to the activity in which you are engaged on behalf of the Society?
• A commercial interest is defined by ACCME as “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.”

• ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

• 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.

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* 3. If you answered YES above, please complete below.

Nature of Relevant Financial Relationship - What was received?
AHS does not want to know how much you received - only what you received. Refer to the #(s) below and put in the 2nd box
1. Consulting fees/honoraria; 2. Speaker’s Bureau; 3. Equity interest/stock options; 4. Equity Interests; 5. Royalty income; 6. Non-royalty payments; 7. Officer or any other fiduciary role; 8. Ownership/partnership/principal; 9. Research grants; 10. Fellowship support; 11. Salary; 12. Intellectual property rights; 13. Other financial benefit, expert witness.
Nature of Relevant Financial Relationship - For what role(s)?
Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

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* 4. If you answered YES above, please complete below.

Nature of Relevant Financial Relationship - What was received?
AHS does not want to know how much you received - only what you received. Refer to the #(s) below and put in the 2nd box
1. Consulting fees/honoraria; 2. Speaker’s Bureau; 3. Equity interest/stock options; 4. Equity Interests; 5. Royalty income; 6. Non-royalty payments; 7. Officer or any other fiduciary role; 8. Ownership/partnership/principal; 9. Research grants; 10. Fellowship support; 11. Salary; 12. Intellectual property rights; 13. Other financial benefit, expert witness.
Nature of Relevant Financial Relationship - For what role(s)?
Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

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* 5. If you answered YES above, please complete below.

Nature of Relevant Financial Relationship - What was received?
AHS does not want to know how much you received - only what you received. Refer to the #(s) below and put in the 2nd box
1. Consulting fees/honoraria; 2. Speaker’s Bureau; 3. Equity interest/stock options; 4. Equity Interests; 5. Royalty income; 6. Non-royalty payments; 7. Officer or any other fiduciary role; 8. Ownership/partnership/principal; 9. Research grants; 10. Fellowship support; 11. Salary; 12. Intellectual property rights; 13. Other financial benefit, expert witness.
Nature of Relevant Financial Relationship - For what role(s)?
Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

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* 6. If you answered YES above, please complete below.

Nature of Relevant Financial Relationship - What was received?
AHS does not want to know how much you received - only what you received. Refer to the #(s) below and put in the 2nd box
1. Consulting fees/honoraria; 2. Speaker’s Bureau; 3. Equity interest/stock options; 4. Equity Interests; 5. Royalty income; 6. Non-royalty payments; 7. Officer or any other fiduciary role; 8. Ownership/partnership/principal; 9. Research grants; 10. Fellowship support; 11. Salary; 12. Intellectual property rights; 13. Other financial benefit, expert witness.
Nature of Relevant Financial Relationship - For what role(s)?
Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

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* 7. If you answered YES above, please complete below.

Nature of Relevant Financial Relationship - What was received?
AHS does not want to know how much you received - only what you received. Refer to the #(s) below and put in the 2nd box
1. Consulting fees/honoraria; 2. Speaker’s Bureau; 3. Equity interest/stock options; 4. Equity Interests; 5. Royalty income; 6. Non-royalty payments; 7. Officer or any other fiduciary role; 8. Ownership/partnership/principal; 9. Research grants; 10. Fellowship support; 11. Salary; 12. Intellectual property rights; 13. Other financial benefit, expert witness.
Nature of Relevant Financial Relationship - For what role(s)?
Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

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* 8. If you have more than 10 financial relationships to disclose, please paste the remaining relationships you need to disclose in the box below.

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* 9. ATTESTATION STATEMENT

I attest that:
- I have disclosed all relevant financial relationships to the Society and will disclose any subsequent relationships (if applicable) to learners verbally (if applicable) and in print.
- I will base my contributions on the best scientific evidence available.
- My contributions will give a balanced view of therapeutic options and be unbiased.
- All scientific research to support a patient care recommendation will conform to generally accepted standards of experimental design, data collection, and analysis.
- If I discuss any off-label product use, I will disclose it to learners.
- I acknowledge that when discussing unlabeled or investigational uses of a commercial product, these uses must be identified as unlabeled; that the use of generic names of products contributes to impartiality; and that if trade names are used, those of several companies should be used.
- I will not accept any honorarium/payment/reimbursement beyond what has been agreed upon directly with the Society.
- My contribution and presentation is HIPAA compliant (e.g., I have only used de-identified patient information).

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* 10. ANNUAL STATEMENT AND ON-GOING OBLIGATION

I have read and considered each item in this form and completed it to the best of my knowledge. I understand that the AHS Board and all members involved in Society governance, such as committees and task forces, programmatic, educational, chapter, and other activities are required to file a signed statement annually with the Society and have an ongoing obligation throughout the year to update or revise their statement as circumstances require. If I have a relevant financial relationship or competing interest related to this activity, I agree to abstain myself from participating in any Society matter which is concerned with the products or interests of the commercial interest.

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* 11. Please type your name and the date below to serve as your signature and to confirm that you agree with the statement above. Please put a forward slash / before and after / your typed name to constitute a lawful electronic signature.

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