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19th Annual Academic Surgical Congress

February 6-8, 2024 | Hilton Washington Hotel, Washington, DC

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DISCLOSURE

PLANNER / FACULTY BIOGRAPHICAL DATA/FINANCIAL RELATIONSHIPS WITH INELIGIBLE COMPANIES FORM
Educational Activity: 19th Annual Academic Surgical Congress
Date(s): February 6 – 8, 2024

Individual’s role(s) in this educational activity: (check all that apply)
Directions: Type information directly into the space provided, or type an ‘X’ in the appropriate box to indicate your response. Do not attach any additional materials.
Mailing Address

Disclosures of Financial Relationships with Ineligible Companies

Employees or owners of an ineligible company may not influence the planning, delivery, or evaluation of an educational activity except in very limited circumstances.
An Ineligible company, as defined by ACCME, is any company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients, or an entity owned or controlled by a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Non-healthcare-related companies, healthcare facilities, and group medical practices are not considered ineligible companies.
1. Are you employed by, or do you have ownership in, any ineligible company?
All individuals in a position to influence content must disclose ALL financial relationships with ineligible companies occurring within the past 24 months.
Please disclose financial relationships of any dollar amount. Examples of different types of financial relationships may include honoraria, consulting fees, speaking fees, salary, ownership interest, royalties, grants, holding a patent on equipment, intellectual property rights, gifts, and any other type of compensation.
2. Over the past 24 months, have you had a financial relationship with an ineligible company?
List
Name of Ineligible Company
Type of Relationship(s)
 
Click ‘+’ to add company
If it is determined that your financial relationship(s) with ineligible company(ies) are relevant, you will be contacted for assistance in mitigating the relationship. All relevant financial relationships with ineligible companies must be mitigated for planners, presenters, authors, content reviewers, and other individuals in a position to influence content prior to the planning of the educational activity.

Electronic Signature:

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FUTURE MEETINGS

February 6-8, 2024
Hilton Washington
Washington, DC

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