Disclosure Form 2010

2010 American Burn Association
Disclosure of Relevant Financial Relationships
Unlabeled or Investigational Use


First Name:
Last Name:
Credentials:  
Institution:
 


ACCME defines "commercial interest" as "any proprietary entity producing health goods or
related services, with the exemption of non-profit or government organizations and non-health
care related companies."

ACCME defines "relevant financial relationships" as "financial relationships in any account
occurring within the past (12) months that create a conflict of interest."

ACCME defines "conflict of interest" as "when an individual has an opportunity to affect
CME content about products or services of a commercial interest with which he/she has a
financial relationship."

 
1. Yes, I do have a relevant financial relationship with commercial interests (listed below) :


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, describe what you or your spouse/partner received (e.g. salary, honorarium, etc.)
The ABA does NOT want to know how much you received.

Third, describe your role.

 
Information of Relevant Financial Relationship 1
 
Name of Commercial Interest?
What was received?  
For what role?
Information of Relevant Financial Relationship 2
Name of Commercial Interest?
What was received?
For what role? :
Information of Relevant Financial Relationship 3
Name of Commercial Interest?
What was received?
For what role?

Examples of Terminology
What was received: Salary, royalties, intellectual property rights, consulting fee, honoraria, ownership
interests (e.g. stocks, stock options, or other ownership interests, excluding diversified mutual funds),
or other financial benefit.

Role(s): Employment, managing positions, independent contractor (including contracted research)
consultation, speaking and teaching membership on advisory committees, review panels, board
membership, "other activities" (please specify).
2. No, I do not have any relevant financial relationships with any commercial interests:
3. My presentation includes the discussion of any unlabeled use of commercial product or investigational
use not yet approved for any purpose.

No

Yes, please specify:

Date Submitted: (mm/dd/yyyy)



The American Burn Association Web site contains general information for burn care professionals. The ABA Web site is not intended to respond to requests for medical information, and the ABA is unable to respond to requests regarding personal medical concerns related to burn injuries. Your physician is the best source for information related to initial treatment, ongoing care, and follow-up issues for burn injuries. If you do not have a physician, please contact the physician referral service at your local burn center or hospital. © copyright 2005 American Burn Association