ABA Disclosure Form
FY 2016-17

July 1, 2016 through June 30, 2017

Disclosure of Relevant Financial or Personal Relationships

 
First Name:
Last Name:
Credentials Institution:
   
Address:
Address2:
City:
State: Zip:
Phone:
Email:


A conflict of interest exists in relation to:

     1.  educational and scientific presentations and publications; and
     2.  burn-related research sponsored by the American Burn Association.

when an individual or his or her spouse or domestic partner has a relevant financial or relevant personal relationship
and has an opportunity to:

     1.  affect the content about products or services of a commercial interest, or
     2.  compromise the integrity of ABA-sponsored burn research.

Definitions:

Commercial Interest: Any proprietary entity producing health goods or 
related services, with the exception of non-profit or government organizations
and non-health care related companies.

Relevant Financial Relationship: Financial relationships in any amount 
occurring within the past (12) months that might create a conflict of interest.

Relevant Personal Relationship:  Non-financial relationship that might affect
career advancement, publishable results, personal value differences with research methods and goals
.


1. Do you have a relevant financial or relevant
personal relationship with commercial interests
(if yes, please list below)?
:


If you answered yes to the above question:

First, list the names of proprietary entities producing health care goods or services, with the 
exemption of non-profits or government organizations and non-health care related companies 
with which you or your spouse/partner have, or have had , a relevant financial relationship 
within the past (12) months.

Second, check the box(es) next to the name(s) of what you or your spouse/partner received (e.g. salary, honorarium, etc.) 
The ABA does NOT want to know how much you received.

Third, check the box(es) next to the item(s) that best describes your role(s).




Enter the commercial interest name and check at least one option in the "What Was Received" AND "For What Role" sections.
Name of Commercial Interest:
 
What was received? (please check all that apply): Salary
  Royalty
  Intellectual Property Rights
  Consulting Fee
  Speaker Fee
  Honoraria
  Ownership Interest*
  Research Grant/Contract
Any Other Personal or Financial Benefit Received?
If yes, please specify:
 
For What Role (please check all that apply): Employment
  Management Position
  Independent Contractor**
  Consulting
  Speaking and Teaching
 
  Membership on Advisory Committees
        or Review Panels
  Board Membership
Other Activities
If yes, please specify:



Enter the commercial interest name and check at least one option in the "What Was Received" AND "For What Role" sections.
Name of Commercial Interest:
 
What was received? (please check all that apply): Salary
  Royalty
  Intellectual Property Rights
  Consulting Fee
  Speaker Fee
  Honoraria
  Ownership Interest*
  Research Grant/Contract
Any Other Personal or Financial Benefit Received?
If yes, please specify:
 
For What Role (please check all that apply): Employment
  Management Position
  Independent Contractor**
  Consulting
  Speaking and Teaching
  Stock or Bond Holder
  Membership on Advisory Committees
        or Review Panels
  Board Membership
Other Activities
If yes, please specify:



Enter the commercial interest name and check at least one option in the "What Was Received" AND "For What Role" sections.
Name of Commercial Interest:
 
What was received? (please check all that apply): Salary
  Royalty
  Intellectual Property Rights
  Consulting Fee
  Speaker Fee
  Honoraria
  Ownership Interest*
  Research Grant/Contract
Any Other Personal or Financial Benefit Received?
If yes, please specify:
 
For What Role (please check all that apply): Employment
  Management Position
  Independent Contractor**
  Consulting
  Speaking and Teaching
  Stock or Bond Holder
  Membership on Advisory Committees
        or Review Panels
  Board Membership
Other Activities
If yes, please specify:

* Ownership interests include stocks, stock options, or other ownership interests, excluding diversified mutual funds

** Independent Contractor can also include contracted research

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