APSNA Declaration of Financial Relationships

Name*

First NameLast Name

Email*

example@example.com

Current Position/Title*

Place of Employment*

Daytime Phone Number

Area CodePhone Number

Name of APSNA Activity*

2026 Annual Conference2027 Annual Conference2028 Annual Conference2025 Annual Conference

Date/Location of APSNA Activity*

April 22-24, 2026 - St. Louis MOApril 2-4, 2025 - Washington DC

Presentation Title*

Select the prospective role(s) that you may have in planning and delivery of educational content during an APSNA activity below: (check all that apply)*

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). 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.

Have you had a relationship with an ineligible company in the past 24 months? (Choose one)

In the past 24 months, I HAVE NOT had any financial relationships with any ineligible companies.In the past 24 months, I HAVE had a financial relationship with an ineligible company/ies.

Instructions - for each financial relationship, enter the following information into the table below:

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.
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.

Please list all financial relationships below:

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

Discussion of ‘Off-Label’ Use*

NO - I will not be discussing/demonstrating any “off-label” use of drugs or medical devices during my presentation.YES - I will be discussing/demonstrating any “off-label” use of drugs or medical devices during my presentation.

If yes, please list what “off-label” use of drugs or medical devices will be discussed/demonstrated:

I attest that the above information is correct as of this date of submission (Signature)*

APSNA Declaration of Financial Relationships

Prospective Role(s) in APSNA Activity

Financial Relationships

Instructions - for each financial relationship, enter the following information into the table below: