Academy of
Breastfeeding Medicine

A worldwide organization of physicians dedicated to the promotion,
protection and support of breastfeeding and human lactation

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:
 

Affiliation:
 

I am a:
 

Disclosure: I have relevant personal financial relationship(s).
 

Select Applicable Type of Financial Relationship Indicate Company Name(s) Self or Spouse
Consultant/Independent Contractor
Grant/Research Support
Salary
Speakers’ Bureau
Stock Shareholder
Royalty
Intellectual Property Rights/Patent Holder
Other

I agree to disclose any unlabeled/unapproved uses of drugs or products referenced in my presentation/materials.
 

By checking here, I attest this annual disclosure is complete and truthful, and will provide any changes to the status of this information occurring prior to the program.
 

* If grant support goes to your institution, it only needs to be reported if you are the named investigator.

SIGNATURE OF REPORTING INDIVIDUAL
 
Please type your full name in CAPITALS to indicate your signature electronically.