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It is the policy of the
GASP to comply with the
Accreditation Council for Continuing Medical Education (ACCME)
Standards for commercial support of CME activities. All faculty
are required to disclose to the program audience any real or apparent
conflict(s) of interest related to this meeting or its content.
Having an interest in or affiliation with the corporate organization
does not necessarily prevent you from making the presentation, but the
relationship must be made known to the audience. Failure to
disclose or false disclosure will require the GASP to identify
a replacement for your participation.
Use the following categories to indicate the type of
financial relationships you are disclosing either for yourself or for
you immediate family as defined above. If an individual is
uncertain about what might constitute a potential financial conflict or
interest they should err on the side of full disclosure.
|
Category |
Code |
Description |
|
Consultant / Advisor |
C |
Consultant fee, paid advisory boards
or fees for attending a meeting (for the past 1 year) |
|
Employee |
E |
Employed by a commercial entity |
|
Lecture Fees |
L |
Lecture fees (honoraria), travel fees
or reimbursements when speaking at the invitation of a commercial
entity (for the past 1 year) |
|
Equity Owner |
O |
Equity ownership/stock options of publicly or privately traded firms
(excluding mutual funds) with manufacturers of commercial sleep
medicine products or commercial sleep medicine services |
|
Patents / Royalty |
P |
Patents and/or royalties that might
be viewed as creating a potential conflict of interest |
|
Grant Support |
S |
Grant support for the past 1 year
(all sources) and all sources used for this project if this form is
an update for a specific talk or manuscript with no time limitation. |
Please select one of the following two options
I DO NOT
have any financial relationship to disclose.
OR
I have the
following financial relationships to disclose:
Company/Organization:
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
Code(s): C
E
L
O
P
S
I intend to
reference unlabeled/unapproved uses of drugs or products in my
presentation (specify drug(s) or product(s) by name for which the
unlabeled use will be discussed.
I have read the Disclosure Requirements and to the best
of my knowledge, the information provided on this form is true and
correct and represents all items for disclosure. I understand that
failure to comply with the disclosure policy, when known and deliberate,
may result in disqualification for two years in similar educational or
related activities. I agree to promptly notify the program
directors is any of this information changes. See
Faculty
Disclosure Statements
Entering your name in the following space acts as my
signature and agreement to the above statement:
req.
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