Disclosure Form – American Burn Association

First Name*

Last Name*

Credentials*

Institution*

Address*

Address 2

City/Town*

State/Province/County*

Zip Code/Postal Code*

Country*

Phone*

Email*

Please describe expertise and years of training specific to the educational activity (1-3 sentences):

Is there a relevant financial relationship? If you answer yes to all 3 items below, you’ve identified a relevant financial relationship with a commercial interest that must be resolved before the activity occurs.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests—unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest.

Information on Relevant Financial or Personal Relationship 1

Relationship (check all that apply):
EmploymentConsultingSpeaking/TeachingStock or bond holderContracted researchOther

Information on Relevant Financial or Personal Relationship 1

Information on Relevant Financial Relationships 2

Information on Relevant Financial Relationships 3