Download Financial and FDA Speaker Disclosure Form

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