Disclosure Statement As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), NASBS must insure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational activities. We are required to identify and resolve all potential conflicts of interest with any individual in a position to influence and/or control the content of CME activities. A potential conflict of interest is considered to exist if the individual and/or their spouse or partner has received financial benefit in any amount from a commercial interest involved in the activity within the past 12 months. A commercial interest is defined as any proprietary entity producing health care goods or services, with the exception of non-profit, government organizations or providers of clinical service directly to patients. All disclosure information will be reviewed to determine if a potential conflict of interest exists. Additional information may be requested to make this determination. Any changes in the disclosure information prior to the presentation should be forwarded to the NASBS office.Name of Program Committee Member* Institution* Email Address* Adminstrative Assistant Name Adminstrative Assistant Email Address Please select the most appropriate answer choice:* I do not have personal financial relationships with any commercial interests. I do have financial relationship(s) with commercial interests. Company* What was Received?*SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above* What was your Role with the Company*EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MemberOtherPlease explain your choice of "other" above* Is this relationship relevant to your participation?* Yes No You answered YES to the question above, so now we need to resolve any potential conflict of interest.* The financial relationship does not relate to my Program Committee assignment. I am changing my relationship with the commercial interest. Other Would you like to submit another statement of financial disclosure for a different company?* Yes No Company* What was Received?*SalaryRoyaltyIndustry-Supported ResearchIntellectual Property RightsConsulting FeeHonorariaOwnership InterestOtherPlease explain your choice of "other" above* What was your Role with the Company*EmploymentManagement PositionIndependent ContractorConsultantSpeaking/TeachingAdvisory CommitteeReview PanelBoard MemberOtherPlease explain your choice of "other" above* Is this relationship relevant to your participation?* Yes No You answered YES to the question above, so now we need to resolve any potential conflict of interest.* The financial relationship does not relate to my Program Committee assignment. I am changing my relationship with the commercial interest. Other PhoneThis field is for validation purposes and should be left unchanged.
