TOA's Disclosure of Relevant Financial Relationships
All TOA speakers are required to fill out this form to ensure that attendees can receive CME credit for listening to the talks.
Overview
The intent of this disclosure is to allow TOA the opportunity to mitigate any relevant financial relationships to assure balance, independence, objectivity and scientific rigor in all of its CME activities. All faculty and planners of TOA-sponsored activities are expected to disclose to TOA all financial relationships with any ineligible company.
Ineligible company: any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Examples of Financial Relationships
Employee · researcher · consultant · advisor · speaker · independent contractor (including contracted research) · royalties or patent beneficiary · executive role · ownership interest
Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.
Financial relationships would include those within the past 24 months with ineligible companies of the person involved in the activity.
Name
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First Name
Last Name
Do you have a financial relationship with an ineligible companies? TOA is seeking a relationship within the past 24 months.
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Yes
No
If yes, please identify the company and the nature of this relationship below. Format: Company X | Nature of Relationship (Owner, consultant, paid speaker, etc.).
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I attest that the information is correct. Please type your name and date:
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