Disclosure of Potential Conflict of Interest Form

  • 1 Current Start
  • 2 Preview
  • 3 Complete

All members of a SPC, speakers, moderators, facilitators, and authors must complete this form. Disclosure must be made to the audience whether you do OR do not have a relationship with for-profit and not-for-profit organizations over the previous 2 years.  


Complete the section below. All financial or "in kind" relationships (not only those relevant to the subject being discussed) encompassing the previous two (2) years must be disclosed. Please indicate the profit and not-for-profit organization(s) with which you have/had affiliations, and briefly explain what connection you have/had with the organization. You must disclose this information to your audience both verbally AND in writing.

For Planning Committee Members and Presenters:

For Presenters Only:

I intend to make therapeutic recommendations for medications that have not received regulatory approval (i.e. off-label use of medications)

You must declare all off-label use to the audience during your presentation.

I acknowledge that the National Standard requires that any descriptions of therapeutic options use generic names (or both generic and trade names) and do not reflect exclusivity and branding.