THE VOICE FOUNDATION

Advancing understanding of the voice through interdisciplinary scientific research & education

ACS Disclosure Form 2019

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The Voice Foundation’s
48th Annual Symposium:
Care of the Professional Voice
May 29 – June 2, 2019 * Philadelphia, PA  USA

Speaker Disclosure of Relevant Financial Relationships

In accordance with ACCME regulations, the American College of Surgeons must ensure that anyone who is in a position to control the content of the education activity has disclosed all financial relationships with any commercial interests. Definitions can be found at:

http://www.accme.org/requirements/accreditation-requirements-cme-providers/policies-and-definitions/financial-relationships-and-conflicts-interest

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.

Failure or refusal to disclose or the inability to manage the identified conflict will result in the withdrawal of the invitation to participate.

The presenting author is required to fill out this form.

If you answered NO to the previous question, you should skip down to the final two check boxes and date fields and then sign this form.

If you answered YES to the previous question, you DO have relevant financial relationships with commercial interests that pertain to the content of your presentation. You need to:

• List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
• Explain what you or your spouse/partner received (i.e. salary, honorarium etc).
• Specify your role.

List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options, etc), or other financial benefit.

• Explain what you or your spouse/partner received (i.e. salary, honorarium etc).

Role: Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, etc.

Specify your role. i.e: Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, etc.

By signing or typing my name below, I certify that I have identified and disclosed all financial relationships with any commercial interests and that all information provided herein is true and correct.

*SCROLL DOWN TO THE END AND CLICK ON THE SUBMIT BUTTON TO SUBMIT THIS FORM*

STOP - Management Only: This section should be completed by a designated official (MD or DOs) only if a commercial interest is reported above.

The designated official (program chair, moderator, etc.) may contact the individual to discuss how the potential conflict can be managed.

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