Please submit your response no later than February 14, 2019. 

Please fill out this form as accurately as possible. Failure to submit a response will result in abstract disqualification. NOTE all authors in your submission must fill out a disclosure form.

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* 1. First and Last Name with Credentials:

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* 2. Email address:

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* 3. Please enter the title(s) of your abstract(s) below:

ACCME Disclosure Information

The Accreditation Council for Continuing Medical Education (ACCME) requires that ASA and SAMBA ensure that the following decisions were made free of the control of a commercial interest. The ACCME defines a "commercial interest" as any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on patients. (Providers of clinical services directly to patients is not considered commercial interest).

1) Identification of CME needs;
2) Determination of educational objectives;
3) Selection and presentation of content;
4) Selection of all persons and organizations that will be in a position to control the content of CME;
5) Selection of educational methods;
6) Evaluation of the activity.

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* 4. I agree to comply with the above ACCME Standards for Commercial Support regarding independence in planning CME activities as listed above.

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* 5. I agree that my presentation will be unbiased, based on the best available evidence and that all elements of the presentation will be free from the control of commercial interests.

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* 6. ASA and SAMBA must be able to show that everyone who is in a position to control the content of an educational activity has disclosed, to the provider, all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. An individual must disclose to the learners any relevant financial relationship(s). If there are no relevant financial relationships, the learners must be informed that no relevant relationship exists.

An individual who refuses to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity.

ASA and SAMBA will implement a mechanism to resolve all conflicts of interest before the educational activity takes place.

Do you, and/or an immediate family member (including your spouse or partner) have a financial relationship as described above?

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* 7. If you answered yes, please complete below by checking the appropriate box(es). Please note that at the recommendation of the Committee on Ethics, presenters should disclose all of the above information, (orally or via slide) at the start of the presentation.

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* 8. If you answered yes, please insert the relevant company name for the support that you indicated in the previous question.

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* 9. I hereby confirm the Disclosure information above is accurate at the time of this submission.

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* 10. I submit my electronic signature by typing my name in this box.

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