Relationship with Industry and Affiliations Form

Personal Commercial Disclosure

This survey will collect information on all conflicts of interest (COI) and relationships with industry (RWI) or other entities involved in the production, marketing, distribution or reselling of health care goods, services, or information consumed by patients, clinicians, and/or support staff (RWI). This includes but is not limited to relationships based on consulting and/or investing as well as relationships with government, not-for-profit, for-profit and academic entities.

COI/RWI of immediate family members including spouses, children, parents, and/or any family member residing with the individual should also be disclosed.
Healthcare company, for the purposes of this document, is any for-profit organization that is involved in the production, marketing, distribution, or reselling of health care goods, services, or information consumed by patients, clinicians, and/or support staff. This does not include the member’s primary location to treat patients, of which the member is likely to be employed. Types of companies include by are not limited to: medical device manufacturers and distributors, pharmaceutical, pharmacy, laboratory testing, electronic health records, hospitals, outpatient care centers, wearable devices for health and fitness, billing services, apps, etc.

Associated healthcare organizations, for the purposes of this document, is any non-profit, government, or academic institutions that represent, advocate, legislate, educate, and/or provide treatment for stakeholders of the healthcare system(s).

Instructions: Please answer each question to the best of your ability. Please disclose all relationships with all organizations. This survey will take about 5-20 minutes to complete depending on how many relationships you have to disclose. If you have more relationships to disclose than the form allows, please email Taleen Safarian tsafarian@asam.org.

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* 1. Name

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* 2. Primary place of employment

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* 3. Title at primary place of employment

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* 4. Do you have any personal commercial relationships to disclose?

Do you, your spouse, domestic partner, and/or any immediate family member residing in your household have any commercial relationships with healthcare companies or associated healthcare organizations that have begun or ended in the past 24 months?

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Yes