Presenter Online Disclosure Form

This is your Online Disclosure Form. This must be completed by all Presenters. Do not forget to include your Name, Email and Name of Abstract. If you are Faculty, please do not use this form. Use the form located HERE.

Click here to download an editable .pdf copy.

*Full Name:
*Email:
*Name of Abstract:

Please place a check in the box by each of the statements below to indicate your understanding and willingness to comply with each of the following statements.

Agree
	I have disclosed all relevant financial relationships to the ASMBS and will disclose any subsequent relationships (if applicable) to learners verbally and in print.
	I will not accept any honoraium/payment/reimbursement beyond what has been agreed upon directly with ASMBS.
	All scientific research to support a patient care recommendation will conform to generally accepted standards of experimental design, data collection and analysis.
	If I discuss any off-label product use, I will disclose it to participants.
	I will base my contributions on the best scientific evidence available regarding this content. My contributions will give a balanced view of therapeutic options and be unbiased.
	If any portion of my presentation slides is not original work, I will obtain necessary copyright permission (As Applicable).
	My contributions will not promote the products or services of any commercial interest related to this content.
	I will not use trade names of health care products or services.
	If applicable, clinical trials will be registered with the National Institutes of Health web site or one of the equivalent web sites and will state this in both the Cover Letter and Methods section of the abstract.

Disclosure: Will your educational contribution include the discussion of any commercial products or services?
Yes No

Please list companies with which you, your spouse and/or your partner currently have had financial relationship(s) within the past 12 months.

1
Company Name:
What was received?:
For what role?:
2
Company Name:
What was received?:
For what role?:
3
Company Name:
What was received?:
For what role?:
4
Company Name:
What was received?:
For what role?:
5
Company Name:
What was received?:
For what role?:

Additional: Based on the statement above, do you have additional disclosure information to input? If so, please enter it in the space below:

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