CME Disclosure Form
Academy of Breastfeeding Medicine: The 22nd Annual International Meeting
November 9 - 12, 2017
For Speakers, Abstract Submitters, Abstract Reviewers, & Planners
Purpose: The information you provide addresses requirements of the Accreditation Council for Continuing Medical Education (ACCME) to help ensure independence in CME activities. Everyone in a position to control the content of a CME activity must disclose all relevant financial relationships with commercial interests to the CME provider. CME providers must resolve current conflicts of interest and disclose any conflicts to participants prior to the beginning of the activity.
Definition: Financial relationships relevant to the CME activity are those in which an individual or the individual’s spouse/domestic partner has a personal financial (any amount) relationship with a commercial interest/entity producing, marketing, re-selling, or distributing health care goods/services consumed by, or used on patients, in the past 12 months, whether relationship has now ended or is currently active.
Name of Discloser:
I am a:
Disclosure: I have relevant personal financial relationship(s).
* If grant support goes to your institution, it only needs to be reported if you are the named investigator.
SIGNATURE OF REPORTING INDIVIDUAL