AGPA Connect 2027 Financial Relationship Disclosure Form Survey

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

First Name

Last Name

Cell Phone
(For use on-site if necessary)

Email Address

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

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

Faculty Speaker, Author, Presenter

Moderator, Panelist

Content Reviewer

Medical Writer, Editor

Other (please specify)

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. Relevant financial relationships determined by AGPA will be disclosed to learners in accordance with accreditation requirements.
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. (Required.)

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

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

4.If you disclosed one or more financial relationships, please provide additional information below. Provide the company name and a description of the relationship in the comment box.

Please list all financial relationship(s) with ineligible companies below:

5.Are any of the financial relationships disclosed above related to the content of this educational activity?

Yes

N/A (I did not disclose any financial relationships)

If yes, please describe how the disclosed financial relationship(s) relate to the content of this educational activity.

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

7.Please check the ONE statement which accurately reflects your use of copyrighted material in your slides and/or handouts.(Required.)

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 2027

8.Was Generative Artificial Intelligence (AI) used in developing your abstract submission and/or presentation materials?
The use of AI for routine spelling or grammar assistance does not need to be disclosed. (Required.)

Yes

If yes, please describe how AI was utilized:

9.If Generative Artificial Intelligence (AI) was used, please acknowledge the following requirements.(Required.)

I am responsible for reviewing and verifying the accuracy and appropriateness of all content included in my presentation, including content generated or modified with the assistance of AI.

N/A

10.Please check the box below to attest to the following statement.(Required.)

I certify that the information provided is complete and accurate to the best of my knowledge and that I will notify AGPA if any information changes before the educational activity.

AGPA Connect 2027 Financial Relationship Disclosure Form

Disclosure of Financial Relationships for Continuing Education