80 Years of Education & Humanitarian Service

Financial Disclosure General

Please complete this form completely before submitting.

ICS-US Section 
Faculty Information Submission Form

Presentation Title
Please submit in Title format.
Example: Laparoscopic Management of Pancreatic Pseudocysts
Will be published as submitted.
(Note: If you are not a speaker indicate your role here, planner or moderator.) *

Faculty / Presenter Information.
Note that last minute substitutions will not be allowed.
Any faculty changes must be submitted and approved in advance of the meeting in order to obtain relevant information about the presenter.

FirstName *
LastName *
Degrees (MD, DO, PhD, etc.) *
List your professional affiliations.
Example: Professor of Surgery, University of Illinois, Chicago, IL

Contact Information

Mailing Address

Street Address *
City *
State *
Zipcode *
Enter the primary phone number where
submitting author can be contacted *

Type of Phone Number
Enter email address for submitting author
Please note that email will be the primary method of communication.
Provide an email address that you check regularly. *


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: *

Clear Selection
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: *

Clear Selection
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.

Clear Selection
Enter your name *
Date *

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

ICS-US Section
83rd Annual Surgical Update

April 28-30, 2022
Renaissance Downtown Hotel - Providence, Rhode Island

Call for Presentations
Submit Today!





1524 N. Lake Shore Drive, Chicago IL 60610 · Phone 312-787-6274 · Fax 312-787-9289 Legal | Privacy | Copyright | GDPR
image widget
image widget