Oregon and Washington Chapters, American College of Surgeons, Disclosure Form for Speakers and Moderators September 26, 2020 Virtual Meeting

You are listed as a speaker, panelist, moderator or presenter at the Oregon-Washington ACS Virtual Meeting on September 26, 2020. Please complete the form below related to disclosures. 

DISCLOSURES

In accordance with ACCME regulations, the American College of Surgeons, as the accredited provider for this activity, must ensure that anyone who is in a position to control the content of the education activity has disclosed to us all relevant financial relationships with any commercial interest (see below for definitions) as it pertains to the content of the presentation. Should it be determined that a conflict of interest exists as a result of a financial relationship you may have, you will be contacted and methods to resolve the conflict will be discussed with you. In addition, all affirmative disclosures must be revealed by a slide at the beginning of the presentation. Failure or refusal to disclose or the inability to resolve the identified conflict will result in the withdrawal of the invitation to participate.
 
Commercial Interest: The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services used on or consumed by patients. Providers of clinical services directly to patients are NOT included in this definition.

Financial Relationships: Relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

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.
 
All CME Planners and Speakers /Moderators/Discussants/Authors/Editors involved in the development and/or presentation of CME content must complete this form. The form must be updated whenever circumstances require. In addition, all affirmative disclosures for speakers must be revealed by a slide at the beginning of the presentation.
 
Failure or refusal to disclose or the inability to manage the identified conflict will result in the withdrawal of the invitation to participate.
 
Check the appropriate box. if you DO have disclosures a Disclosure Management Form will be completed. We will contact you to discuss managing the potential conflict. 
Disclosures *
Disclosure Information
If you HAVE disclosures:
• List the names of companies that you (or your Spouse/Partner) have a financial relationship with currently or have had in the last 12 months.
• Explain what you (or your Spouse/Partner) received (i.e. salary, honorarium etc.).
• Specify your role (i.e. consultant, board member, etc.)
• If it is determined that a conflict of interest exists as a result of a financial relationship you have, you will be contacted and methods to manage the conflict will be discussed with you.
 
Company Name
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What I/Spouse/Partner Received
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For What Role?
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Please note that attesting to the following conditions are required: *
By signing or typing my name below, I certify that I have identified and disclosed all financial relationships with any commercial interests (in the last calendar year) and that all information provided herein is true and correct.
Name:
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Date:
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Oregon Chapter ACS | 3340 Commercial St SE, Suite 220 | Salem, OR 97302 | Tel: 503-371-7457 | Email: harvey@spiremanagement.com | Website: www.oregonchapteracs.org