Financial Disclosure
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Disclosure of All Financial Relationships
As a prospective planner or faculty member for a continuing education activity of the International College of Surgeons-United States Section (ICSUS), we would like to ask for your help in protecting our learning environment from industry influence. 

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at info@ficsonline.org or 312-787-6274. For more information about the policies of the ICSUS please visit our website at www.ficsonline.org
Enter your full name (including degree - MD, DO, PhD, etc. Do not include FACS, FICS or other similar organizational affiliations.) *
Enter your Email Address where we can most easily contact you. *
Select the prospective role(s) in education that you may have in the planning and/or delivery of this education (choose all that apply) *
Required
If you are a speaker/faculty in a continuing education program, please indicate the title of your presentation. Example - Update on Transplant Surgery
If your submission relates to a specific educational activity, please indicate the activity name and location. Example - 2024 Annual Surgical Update, Philadelphia, PA
Instructions
Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below).  For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.
Enter the Name of Ineligible Company
An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit www.accme.org/standards.
Enter the Nature of Financial Relationship 
Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.
Has the Relationship Ended?  
If the financial relationship existed during the last 24 months, but has now ended, please indicate this information. This will help the education staff determine if any mitigation steps need to be taken.
Please be sure to list your relationships as follows:
Ethicon - Speaker - Ongoing
Synthes - Consultant - Ended July 2023
Pfizer - Research Grant - Sep 2022 to August 2023

Use a Hard Return after each relationship.
Or check the box below if no relationships to report.
By entering today's date, I attest that the above information is correct as of this submission.
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