ICHS Symposium Disclosure Form

Disclosure Form

ICHS 24th Biennial Symposium: May 14-17, 2026
Financial Relationships

FOR PLANNERS, FACULTY, AND OTHERS IN CONTROL OF ACTIVITY CONTENT
Name*

Name
Email Address
example@example.com
Role*

PlannerFacultyReviewerOther
To be Completed by the Planner, Faculty, or Others Who May Control Educational Content

Please disclose all financial relationships you have had in the past 24 months with ineligible entities (definition below). For each financial relationship, enter the name of the entity and the nature of the financial relationship. There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible entities. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education. You do not need to disclose the financial relationships of your spouse or partner.
An ineligible entity is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples, visit accme.org/standards.
Please select the statement that is accurate regarding your financial relationships with ineligible companies.*

I have had, or do have, financial relationship(s) with ineligible companies and have disclosed them here.In the past 24 months, I have not had any financial relationships with ineligible companies.
If you have not had any financial relationships with ineligible companies, please skip down to attest and sign this form.

If you DO have a financial relationship, please disclose the information for EACH company below.
Company 1
Please select the nature of the financial relationship for the first company.
Please list the company the above relationship pertains to.
Has this relationship ended? If yes, please explain below.

NoYes
If you answered yes, please explain.
Company 2
Please select the nature of the financial relationship for the first company.
Please list the company the above relationship pertains to.
Has this relationship ended? If yes, please explain below.

NoYes
If you answered yes, please explain.
Additional Company Relationships

If you have more than two financial relationships with ineligible companies, please use the field below to describe them as instructed.
Please indicate the company name, nature of the relationship and status of that financial relationship as of today.
Select this option to attest:

I attest that the above information is correct as of the date of submission.
Signature*
Date/Time
PIM ID (PIM Office to assign)
Should be Empty:

Disclosure Form

Financial Relationships

To be Completed by the Planner, Faculty, or Others Who May Control Educational Content

Company 1

Company 2

Additional Company Relationships