Western Trauma Association



*First Name:    *Last Name:   

*Email Address:    ACS Member ID Number (if readily available):   

I am a member of the program committee


Abstract Presenters:
Please reference your Abstract Submission Confirmation email for the two items below. If you are unsure of these values, please contact us for assistance.
Abstract ID:    Abstract Title:

Other Speakers:
Presentation Title:

In accordance with ACCME regulations, the American College of Surgeons must ensure that anyone who is in a position to control the content of the education activity has disclosed to us all relevant financial relationships with any commercial interest (see below for definitions) as it pertains to the content of the presentation. Should it be determined that a conflict of interest exists as a result of a financial relationship you may have, you will be contacted and methods to resolve the conflict will be discussed with you. In addition, all affirmative disclosures must be revealed by a slide at the beginning of the presentation. Failure or refusal to disclose or the inability to resolve the identified conflict will result in the withdrawal of the invitation to participate.



* I do not have any relevant financial relationships with commercial interests that pertain to the content of my presentation
* I do have any relevant financial relationships with commercial interests that pertain to the content of my presentation


Nature of Relevant Financial Relationships

  • List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
  • Explain what you or your spouse/partner received (ex: salary, honorarium, etc).
  • Specify your role.

Commercial Interest (Ex. Company 'X') What I or spouse/partner receieved (Ex. Honorarium) My role (Ex. Speaker)

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. My Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

If your presentation describes the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage, it is your responsibility to disclose this information verbally to the learner during your presentation.

Glossary of Terms


Commercial Interest
A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests.

Financial Relationships
Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant Financial Relationships
The ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of Interest
Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

* I agree that I will not accept honorarium, travel expensies, in-kind contributions, or any other support from commercial companies in connection with this activity


* If any of the information reported above changes, I will notify ACS immediately and update this form accordingly.


By signing or typing my name below, I certify that I have identified and disclosed all financial relationships with any commercial interests and that all information provided herein is true and correct.
*Signature:     Date:


Management Section: This section should only be completed by a designated official (MD or DOs) if a commercial interest is reported above.

The designated official (program chair, moderator, etc) may email or phone the speaker to discuss how the potential conflict can be managed.
Name of Designated Official (MD/DO) Completing Form:
Relevant Conflict of Interest Identified Above:
Presentation Title (if speaker, moderator, etc):
Management Plan (Please select all that apply):
(Recommended ways to manage the conflict)
Planning Committee Member will recuse them self from the relevant portion of the meeting.
Presentation will include validation of evidence based content.
Peer review of content will be done to ensure absence of bias and, if necessary, content will be restructured.
Content that has the potential to include a conflict will be assigned to another individual.
The speaker will offer no recommendations and limit content to scientific/research data.
Another speaker will be assigned to address broader implications and recommendations.
Determination that the conflict of interest is not relevant to the content of the presentation.
Other:

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