Society for PAs in Pediatrics
Annual CME Conference, September 14-16, 2018
CME Faculty Disclosure
A conflict of interest may be considered to exist if a faculty member of an educational activity, or spouse or partner of that person, has financial relationships with the grantor or any commercial interest(s) that may have a direct impact on the content of the program. Financial relationship is defined as being a shareholder, consultant, grant recipient, research participant, employee, and/or recipient of other financial or material support. The participants in this CME activity must be made aware of any such financial relationship(s). Full disclosure of any such financial relationship is required of all persons who may have control over the content.This disclosure policy is intended to protect all parties involved from any potential conflict of interest that may arise.
Name
*
First Name
Last Name
Suffix
Session Title
*
Do you intend to discuss any unapproved/investigational use of a commercial product/device during this educational activity?
*
Please Select
no
yes
I attest that my presentation will provide a balanced view of therapeutic options and will be entirely free of promotional bias.
*
Please Select
yes
no
Non-Declaration Statement
I declare that neither I nor my spouse or partner has a current financial relationship with the grantor and/or any commercial interest(s) that may have a direct interest in the subject matter of the CME program. (skip fields below then sign and date form at the bottom)
Declaration Statement
I or my spouse or partner currently has a financial relationship with the grantor and/or commercial interest(s) that may have a direct interest in the subject matter of the CME program.
Name of Individual with Relationship
First Name
Last Name
Suffix
Honorarium
Name of Commercial Interest
Consultant
Name of Commercial Interest
Grants/Research Support
Name of Commercial Interest
Stock Shareholder
Name of Commercial Interest
Other Financial or Material Support
Name of Commercial Interest
Speaker's Bureau
Name of Commercial Interest
Employee
Name of Commercial Interest
Other
Name of Commercial Interest
Signature (use your mouse or touchpad to sign)
*
Submit
Should be Empty: