Live Course Faculty Agreement and Disclosure

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It is the policy of the American Society of Echocardiography (ASE) Continuing Medical Education Program to ensure balance, independence, objectivity and scientific rigor in all its sponsored or jointly sponsored educational activities. All faculty participating in any ASE sponsored activities are expected to disclose to the audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the presentation topic, including relationships with biomedical device manufacturers, or other corporations whose products or services are related to the subject matter. All slide and handout materials must be free from pharmaceutical identification and trade name of drugs so as to avoid the appearance of commercial bias. Use of the aforementioned identification material will be viewed as a violation against the Essentials and Standards of the ACCME, compromising the scientific balance of the program and offering bias to the presentation. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly and resolved prior the activity.
Do you accept the invitation to speak at this ASE live course? *
YesNo
If yes, please complete the disclosure information below.
Faculty Name *
Credentials *
Business Address Line 1
Business Address Line 2
City *
State
Zip Code
Business Phone
Email *
Instructions Disclosure of Financial Relationships
ASE policy requires review of disclosure information for potential conflicts of interest and resolution mechanisms that will eliminate the potential perception of bias with respect to your role in this CME activity. The potential for bias occurs when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest. To eliminate the potential for commercial bias in its educational activities, ASE requires all faculty members to disclose relationships that directly relate to the subject matter of their assigned presentation topic(s). If you refuse to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of this CME activity. The ACCME defines a commercial interest as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, with the exception of nonprofit or government organizations and non-health care-related companies. Providers of clinical services directly to patients are not considered a commercial interest.
Disclosure *
*Within the past 12 months, I and/or my spouse/significant other have received support from or had a relationship with the following commercial interests (indicate all that apply) that may have a direct bearing on the subject matter of my presentation topic(s). Disclosure should include relationships in any amount.I have no disclosure to make.I have the following relationships to report:
Company Name #1
Company #1 Relationship
Check all that apply.Speaker/Speakers’ BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Company Name #2
Company #2 Relationship
Check all that apply.Speaker/Speakers' BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Company Name #3
Company #3 Relationship
Check all that apply.Speaker/Speakers’ BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Company Name #4
Company #4 Relationship
Check all that apply.Speaker/Speakers’ BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Company Name #5
Company #5 Relationship
Check all that apply.Speaker/Speakers’ BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Company Name #6
Company #6 Relationship
Check all that apply.Speaker/Speakers’ BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Company Name #7
Company #7 Relationship
Check all that apply.Speaker/Speakers’ BureauConsultant, AdvisorStock Ownership (not including stocks owned in a management portfolio)Research grant (including grants in which you are listed PI)Spouse Employment AffiliationRoyalty, PatentsCorporate research collaboration (including trials/product testing)EmploymentOther
Please describe any additional relevant disclosure below:
I will be using slides, scripts, or other teaching materials that were provided from a commercial source.
YesNo
If you answered yes above, please describe:
Faculty Agreement
*I understand that the information presented to the learner must be unbiased, scientifically balanced, and based on best available evidence and best practices in medicine. I agree to present all reasonable clinical alternatives when making practice recommendations. I attest that relationships with commercial interests will not influence or bias my presentation and/or planning of the CME activity.YesNo
*I agree to comply with patient confidentiality as outline in the Health Insurance Portability and Accountability Act. (HIPAA), by removing any and all patient identifiers from my presentation(s)YesNo
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Live Course Faculty Agreement and Disclosure

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