ACS-100-logo-for-PowerPoint-300x102

The Voice Foundation’s
53rd Anniversary Symposium:
Care of the Professional Voice
May 29 – June 2, 2024, Philadelphia, PA  USA

Speaker Disclosure of Relevant Financial Relationships

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.

ACS Disclosure Form

ANNUAL DISCLOSURE OF FINANCIAL INTERESTS

The Voice Foundation’s 53rd Anniversary Symposium: Care of the Professional Voice
The presenting author is required to fill out this form.
Name(Required)
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 (termed by the ACCME as “ineligible companies”, defined below) in the last 24 months prior to their involvement of the educational activity.

Ineligible Company: Defined by the ACCME 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. If applicable, the first author is responsible for collecting and submitting disclosure information on behalf of all other authors/contributors. 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.

Do you (and/or your Spouse/Partner) have personal financial relationships with any ineligible companies as defined above.(Required)

IF YOU ANSWERED *NO* to the previous question, you should skip down to the final three check boxes and date field 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 companies that you (or your Spouse/Partner) have a financial relationship with currently or have had in the last 24 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.

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.

FINAL THREE CHECK BOXES

Agree(Required)
Agree(Required)
Agree_Changes(Required)
MM slash DD slash YYYY
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.

Save