International Symposium on Prostate, Androgens and Menís Sexual Health
InterContinental Hotel Berlin - 21 to 23 June 2013
Conflict of Interest Disclosure Form
Please carefully ready and complete the disclosure form below.
Title of CME Activity:
International Symposium on Prostate, Androgens and Men's Sexual Health
21 to 23 June 2013
Location of Activity:
CME Presenter/Author Name:
Presenter (invited presentation or abstract presentation)
Author (author or co-author of an accepted abstract)
Presenter and Author (any combination of 1. and 2.)
Other (if you do not present and are not an author of an abstract)
please complete questions 3+4+5, sign and date below.
please complete question 4A, sign and date below.
(See glossary of terms for guidance)
By signing this document, I agree to the following elements as expected of individuals involved in the planning and implementation of educational activities certified by the University of Oklahoma College of Medicine, Office of Continuing Medical Education.
must answer questions 3+4+5. Do not forget question 4B.
must answer Question 4A.
All CME speakers must read, agree, and check the
following statements. I will:
Teach to the competencies identified by objectives
Deliver balanced and objective evidence-based content
Present the source and type or level of evidence (
e.g. common practice, expert opinion, case series, case-control study, clinical guidelines, randomized controlled trial, systematic review, meta-analysis, etc.
Disclose all related financial relationships
Notify participants of any off-label or investigational treatments discussed within my presentation or during the question and answer period
I or my spouse/partner presently (within the past 12 months) has relevant financial relationships with a commercial interest(s) as identified below:
[Please indicate the full name of the commercial interest(s)/organization(s) next to the best description of the relationship(s).]
Stock shareholder (directly purchased):
Other financial or material support:
Employee of a commercial interest organization
(as described here)
NONE (If none, skip to question 5.)
Will your presentation(s) include discussion of any products or services from the above listed commercial interest(s)?
Yes, it will
No, it will not
I will make clinical recommendations in this/these presentation(s).
By selecting "I Agree" I represent and acknowledge that:
I have read, understood, and consented to electronic delivery of, the disclosures above.
I intend the act of selecting "I Agree" to be my legal signature to this agreement.