TOA Disclosure of Relevant Financial Relationships
Texas Orthopaedic Association
Disclosure of Relevant Financial Relationships
By Speakers and their Spouses of CME Activities

The intent of this disclosure is to allow TOA the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its CME activities. All faculty and planners of TOA-sponsored activities are expected to disclose to TOA any relevant financial relationships with any commercial interest that produces health care goods or services concerned with the content of an educational presentation.

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 she/he has a financial relationship.

Commercial interest: A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Financial relationships: 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, teaching, membership on advisory committees or review panels, board membership,
and other activities for which remuneration is received or expected.

Relevant financial relationships would include those within the past 24 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, grant, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, research, membership on advisory committees or review panels, board membership, and other activities (please specify).

PLEASE COMPLETE AND SIGN ON THE SIGNATURE LINE BELOW
Sign in to Google to save your progress. Learn more
Speaker/Planner Name: *
Do you have financial relationships with ineligible companies? Please disclose any financial relationship within the past 24 months. *
If yes, please identify the company and the nature of this relationship below. Format: Company X | Nature of Relationship (Owner, consultant, paid speaker, etc.) *
I attest that the information is correct.  Date of electronic signature. *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy