LSA Disclosure Information

During the abstract submission process, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form no later than Sunday, November 10, 2024.

For your abstract to be considered, all authors listed on the abstract, must submit a disclosure form.

Please note: Once an abstract is accepted and confirmed for the meeting, the individual presenting at the meeting will need to disclose in the ASA’s disclosure system.

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at janna@lsahq.org.

Full Name*

First NameMiddle InitialLast NameSuffix

Choose One*

Your Email*

example@example.com

ASA Member Number

Individual’s prospective role(s) in education*

PresenterLead AuthorAuthor

Presentation Title(s)*

Please select one*

In the past 24 months, I have not had any financial relationships with any ineligible companies.In the past 24 months, I do have a financial relationships with any ineligible companies.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Enter the Name of Ineligible Company
An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.

Enter the Nature of Financial Relationship
Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and 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.

Has the Relationship Ended?
If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken.

Disclose your information*

	Company Name	Nature of Financial Relationship	Has the Relationship Ended?
Disclosure 1
Disclosure 2
Disclosure 3
Disclosure 4
Disclosure 5
Disclosure 6
Disclosure 7
Disclosure 8

I attest that the above information is correct as of this date of submission. *

Date

LSA Disclosure Form

About Presentation

Disclosure of Financial Information