ACP Disclosure of Relevant Financial Relationships and Conflicts of Interest (COI) Form

ACP DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS AND CONFLICTS OF INTEREST (COI)
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DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS AND CONFLICTS OF INTEREST (COI)
Relevant Financial Relationships
For a person involved in the planning, administering or presentation of a continuing dental education activity, ADA CERP considers relevant financial relationships to be financial relationships in any amount, occurring in the last 12 months, that are relevant to the content of the CDE activity and that may create a conflict of interest. ADA CERP considers relevant financial relationships of the person involved in the CDE activity to include financial relationships of a family member. Relevant financial relationships must be disclosed to participants in CDE activities in writing.

Conflicts of Interest (COI)
ADA CERP considers that a conflict of interest may exist when an individual has an opportunity to affect the content of continuing dental education activities regarding products or services of a commercial interest with which he/she has a financial relationship.
DISCLOSURE (check one box below and complete as appropriate):
I, the undersigned, declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presentation.I, the undersigned, (or an immediate family member), have a financial interest/arrangement or affiliation with the corporate organization offering financial support or grant monies for this continuing dental education program, or I do have a financial interest in any commercial product(s) or services I will discuss in the presentation.
No Financial Relationships Exist with Commerical / Financial Interest:

I, the undersigned, declare that neither I nor any member of my family have a financial interest/arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program.
To Declare Existing Commercial / Financial Interests:

Having an interest in or an affiliation with a corporate organization does not necessarily prevent you from making a presentation, but the relationship must be made known to the audience. Failure to disclose or a false disclosure will require the American College of Prosthodontists to remove you from the program and to identify a replacement for your participation.

I, the undersigned (or an immediate family member), have a financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for or related to the content of this continuing dental education program as follows. There is no need to disclose the actual financial value of any affiliation.
Please enter the financial interest's name below, add as many as needed.
Grants / Research Support:
Company Name(s)
Consultant:
Company Name(s)
Stock Shareholder (Directly Purchased):
Company Name(s)
Governance:
Company Name(s)
Honorarium:
Company Name(s)
Employee, Full or Part Time:
Company Name(s)
Other Financial or Material Support
Company Name(s) and describe nature of relationship
I understand that this form will be available for review by program participants.
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Date*

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Thank you for filling out the ACP Conflict of Interest (COI) Disclosure Form.
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ACP DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS AND CONFLICTS OF INTEREST (COI)

DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS AND CONFLICTS OF INTEREST (COI)

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