16th World Meeting on Sexual Medicine
Hotel Transamérica São Paulo, 8 to 12 October 2014
Conflict of Interest Disclosure Form
Please carefully ready and complete the disclosure form below.
Title of CME Activity:
16th World Meeting on Sexual Medicine
Activity Number/Date:
8 to 12 October 2014
Location of Activity:
Sao Paulo, Brazil
1.
CME Presenter/Author Name:
First Name
Last Name
Institute/affiliation
2.
Disclosing as:
1.
Presenter (invited presentation or abstract presentation)
2.
Author (author or co-author of an accepted abstract)
3.
Presenter and Author (any combination of 1. and 2.)
4.
Moderator / Other (if you do not present and are not an author of an abstract)
Instructions
:
Presenters:
please complete questions 3+4+5, sign and date below.
Authors:
please complete question 4A, sign and date below.
Moderators / Other:
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 accredited/certified educational activities.
Presenters
must answer questions 3+4+5. Do not forget question 4B.
Authors / Moderators / Other
must answer Question 4A.
3.
All CME speakers must read, agree, and check the
all
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
4.
A.
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).]
Grants/research support:
Consultant:
Stock shareholder (directly purchased):
Honorarium:
Other financial or material support:
Employee of a commercial interest organization
(as described here)
:
NONE (If none, skip to question 5.)
B.
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
5.
I will make clinical recommendations in this/these presentation(s).
Yes
No
SIGNATURE
:
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.
I Agree
I Disagree
Email address
Telephone Number
Date (Y-M-D)