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* 1. Welcome to the American Geriatrics Society's Conflict of Interest Disclosure Site.

We are looking forward to having the opportunity to include you as a reviewer in the accredited continuing education activity, the AGS 2022 Annual Meeting.

Why am I receiving this communication?
The American Geriatrics Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME®). We appreciate your help in partnering with us to follow accreditation guidelines and help us create high-quality education that is independent of industry influence.

In order to participate as a person who will be able to control the educational content of this accredited CE activity, we ask that you disclose all financial relationships with any ineligible companies that you have had over the past 24 months.

We define ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; you must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask you to disclose regardless of whether you view the financial relationships as relevant to the education.

For more information on the Standards for Integrity and Independence in Accredited Continuing Education, please visit accme.org/standards.

Why do we collect this information?
Since healthcare professionals serve as the trusted authorities when advising patients, they must protect their learning environment from industry influence to ensure they remain true to their ethical commitments.

Many healthcare professionals have financial relationships with ineligible companies. By identifying and mitigating relevant financial relationships, we work together to create a protected space to learn, teach, and engage in scientific discourse free from influence from organizations that may have an incentive to insert commercial bias into education.

What are the next steps in this process?
After we receive your disclosure information, we will review it to determine whether your financial relationships are relevant to the education. Please note: the identification of relevant financial relationships does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity.

To help us meet these expectations, please complete this survey to share all financial relationships you have had with ineligible companies during the past 24 months. This information is necessary in order for us to be able to move to the next steps in planning this continuing education activity.

Contact Information: Please enter your complete contact information below. Your name will be published exactly as you list it. Please include your degree(s)/credentials.

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* 2. What is your prospective role(s) that you may have in the planning and delivery of AGS22? (choose all that apply)

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* 3. As a prospective reviewer, planner, or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. 

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below).

For each financial relationship, you will be asked to 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. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Ineligible Companies
An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.

Financial Relationships
Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed.

Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

Do you have any financial relationships with ineligible companies to disclose?

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* 4. Disclosure of Financial Relationships:  Company 1

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* 5. Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please enter YES. This will help the education staff determine if any mitigation steps need to be taken

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* 6. Do you have additional financial relationships with ineligible companies to disclose?

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* 7. Disclosure of Financial Relationships: Company 2

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* 8. Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please enter YES. This will help the education staff determine if any mitigation steps need to be taken

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* 9. Do you have additional financial relationships with ineligible companies to disclose?

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* 10. Disclosure of Financial Relationships: Company 3

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* 11. Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please enter YES. This will help the education staff determine if any mitigation steps need to be taken

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* 12. Please indicate your area of expertise below:

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* 13. Which abstract submission categories are you interested in reviewing?  Check all that applies.

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* 14. Please upload a brief biosketch by clicking on the "Choose File" option below.

PDF, DOC, DOCX file types only.
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