Financial Disclosure General | International College of Surgeons, US Section

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ICS-US Section
Faculty Information Submission Form

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Example: Laparoscopic Management of Pancreatic Pseudocysts
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FINANCIAL DISCLOSURES

The Importance of Identification. In order for the audience at a CME activity sponsored by the International College of Surgeons-United States Section (ICSUS) to evaluate information, analysis and opinions presented during the activity, it is crucial that the audience be informed of ALL financial relationships of a planner, speaker, author or peer-reviewer. All planners, speakers, authors and peer-reviewers for a CME activity are required to submit FULL DISCLOSURE of ALL financial relationships prior to the CME activity.

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

A conflict of interest (COI) occurs when there is a divergence between an individual's private interests and his or her professional obligations to ICSUS such that an independent observer might reasonably question whether the individual's professional actions or decisions are determined by considerations of personal gain, financial or otherwise. A conflict of interest depends on the situation, and not on the character or actions of the individual.

A COI is present when a planner, speaker, author or peer-reviewer has both a current financial relationship with a commercial interest and the opportunity to affect content relevant to products or services of that commercial interest. Conflicts of interest are identified through an analysis of the information disclosed and an understanding of the planned content of the CME.

In order for the ICSUS to determine whether a conflict of interest exists, you must provide information about all relevant financial relationships you have with a commercial interest.

I have read the policies (click here to view complete policy and FAQs) regarding “relevant financial disclosure” and I attest that:

To the best of my knowledge: *

I DO NOT have any financial relationships to report.

I DO have the following relationships to report...

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Relationship List

Speakers are also required to report if their presentation includes discussion(s) of investigational products or products not labeled for use.

Off-Label Disclosure: (Including Generic Trade Names and Reporting Scientific Research) Presentations must give a balanced view of options. Faculty use of generic names will contribute to this impartiality. Presentations supported by a commercial entity reporting the results of scientific research must conform to the generally accepted standards of experimental design, data collection and analysis. When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity it is required that the speaker disclose that the product is not labeled for the use under discussion or that the product is still investigational.

This Presentation: *

DOES NOT include information about product(s) not labeled for use or investigational

DOES include information about procedure(s)/product(s) not labeled for use and/or are investigational.
I understand that I must disclose this information to the audience prior to the presentation.

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Off-Label Procedure(s)/Product(s) under investigation include:

By clicking the following button and submitting the information above you acknowledge that you are digitally signing this document and are legally bound as if you submitted this information in print form.

In addition, by submitting this form you agree that you have reviewed the ICS-US Policies on Commercial Support and will comply with the terms and conditions contained therein.
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I agree to comply with the ICS-US Policies on Commercial Support.

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