- New Mexico Academy of Family Physicians

Event

Topic Title *

Name *

First

Last

Please include any credentials after your last name (eg: MD, DO, MPH, NP, etc)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Email

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Disclosure of Financial Relationships within 12 Months of Date of this Form

Select the situation that best describes you. *
Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services.
I have or an immediate family member has a financial relationship or interest with a proprietary entity producing health care goods or services.

Please check the relationship(s). Check all that apply. *
Research Grants
Speakers' Bureaus
Ownership
Consultant for Fee
Stock/Bond Holdings (excluding mutual funds)
Employment
Partnership
Others

Please list other(s) *

How many relationships do you need to disclose? *

Please indicate the names of the organizations with which you have a financial relationship or interest, and the specific clinical areas that correspond to the relationship.

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Organization with Which Relationship Exists *
Org #2 *
Org #3 *
Org #4 *
Org #5 *
Org #6 *
Org #7 *
Org #8 *
Org #9 *
Org #10 *
Clinical Area Involved *
Clinical area #2 *
Clinical area #3 *
Clinical area #4 *
Clinical area #5 *
Clinical area #6 *
Clinical area #7 *
Clinical area #8 *
Clinical area #9 *
Clinical area #10 *

You indicated a relationship with a Speakers Bureau. Please answer the following questions in relation:

Did you participate in company-provided speaker training related to your proposed topic?

Did you travel to participate in this training?

Did the company provide you with slides of the presentation in which you were trained as a speaker?

Did the company pay the travel/lodging/other expenses?

Did you receive an honorarium or consulting fee for participating in this training?

Have you received any other type of compensation from the company?

Please specify: *

When serving as faculty for the NMCAAFP, will you use slides provided by a proprietary entity for your presentation/handout materials?

Will your topic involve information or data obtained from commercial speaker training?

Disclosure of Unlabeled/Investigational Uses of Products

Will the content of your material(s)/presentation(s) in this CME activity include discussion of unapproved or investigational uses of products or devices? *
No, my content DOES NOT include discussion of unapproved or investigational uses of products or devices.
Yes, my content DOES.

The content of my material(s)/presentation(s) in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated: *

I have read the NMCAAFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require the NMCAAFP to identify a replacement.

Signature *

Speaker Disclosure Form

Disclosure of Financial Relationships within 12 Months of Date of this Form

Disclosure of Unlabeled/Investigational Uses of Products