Speaker Form

Speaker Information

Name (Please enter name as it should appear in the final program)
Name (Please enter name as it should appear in the final program)
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Maximum file size: 268.44MB

Maximum file size: 268.44MB

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Travel Plans

Presentation

AL ACS Disclosure Form

In accordance with ACCME regulations (ACCME Standard 3), the American College of Surgeons must ensure that anyone who is able to control the content of the activity has disclosed all financial relationships with any ineligible companies in the 24 months prior to their involvement in the educational activity.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME system (ineligible companies) are those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.

Financial Relationships: Financial relationships are relevant if the following three conditions are met for the individual who will control content of the education: 1) a financial relationship, in any amount, exists between the person in control of content and an ineligible company; 2) the financial relationship existed in the last 24 months; 3) the content of the education is related to the products of an ineligible company with whom the person has a financial relationship.

Name
Name

All CME Planners and Speakers /Moderators/Discussants/Authors/Editors involved in the development and/or presentation of CME content must complete this form. This form must be updated whenever circumstances require. As relevant, all disclosure information for speakers must be revealed by a slide at the beginning of the presentation.

Relationship
  • I agree that I will not directly accept honoraria, travel expenses, in-kind contributions, or any other compensation from ineligible companies in connection with this activity (Support provided with a letter of agreement may be permissible).
  • If any of the information reported above changes, I will notify AL ACS immediately and update this form accordingly.

By signing or typing my name below, I certify that I have identified and disclosed all financial relationships with any ineligible companies (in the last 24 months) and that all information provided herein is true and correct.