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SNM CONTINUING MEDICAL EDUCATION FULL DISCLOSURE STATEMENT FORM I. DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM FINANCIAL DISCLOSURE: As a sponsor accredited by the ACCME, the Society of Nuclear Medicine must ensure that its individually sponsored or jointly sponsored CME activities are independent and free of commercial bias. All in a position to control the content of a CME activity – speakers, authors, planning committee members, organizers, moderators and staff are required to disclose any relevant financial interest or other relationship occurring within the past 12 months with (1) the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation and (2) with any commercial supporters of the activity. (“Relevant“ financial interest or other relationship can include such things as grants or research support, employee, consultant, major stockholder, member of speakers’ bureau, etc.). The intent of this disclosure is not to prevent anyone with a relevant financial or other relationship from participating, but rather to ensure that no conflicts of interest exist prior to confirmation of the individual for CME credit assignment. It remains for the audience to determine whether the speaker's interests or relationships may influence the presentation with regard to exposition or conclusion. SNM will disqualify any individual who refuses to disclose relevant financial relationships. NAME: Please check: ____Faculty ____Author ____Planning Group/Committee _____Editorial Board ____SNM CE Committee ____SNM Council Member ____Abstract reviewer ____Abstract author/presenter ____Staff Name of CME Activity: SNM 2008 Mid-Winter Meeting Clinical/Non-Clinical Topics or Title of Presentation:_________________________________________________________________________________________ _____Neither I nor any member of my immediate family member has a relevant financial interest/arrangement or affiliation currently or within the past 12 months with the manufacturer(s) of any of the products or provider(s) of any of the services used on patients related to the content of this CME activity. OR ____ I have or ___________________________ an immediate family has a relevant financial interest/arrangement or affiliation currently or within the past 12 months with the manufacturer(s) of any of the products or provider(s) of any of the services used on patients related to the content of this CME activity. The financial relationships are identified as follows: Relevant Financial Relationships Related to Your Content (check all that apply) Name of Commercial Organization Research Grant (including funding to an institution for contracted research) Speakers’ Bureau Investment Interest (excluding Mutual Funds) Consultant Owner Other (Identify) SECTION B - FDA DISCLOSURE FDA DISCLOSURE: If a device or drug requiring FDA approval is identified as an important component of your presentation, you must indicate the FDA status of those devices as Approved, Investigational Device/Drug, or Not Approved for Distribution in the United States. Please list the name of the devices and drugs in your presentation requiring FDA approval and check their appropriate status. Device/Drug Approved Investigational Not Approved 1. 2. 3. I do not intend to discuss an unapproved/investigative use of a commercial product/device Print Name Signature Date