• If you do not complete and submit Sections I and II of the form below, you cannot speak at this CME activity, or participate in its planning or implementation.

    Please provide the requested identification information and check the participant agreement boxes to acknowledge that you have read this form and agree to all its provisions.

  • IDENTIFICATION INFORMATION

  • Please select one
  • Please select one
  • I. PARTICIPANT AGREEMENT: OBSERVANCE OF ISMRM POLICIES - MANDATORY

    Please check each box below to acknowledge that you have read and understand each section, and will satisfy all these obligations and responsibilities of meeting organizers and speakers.
    *Note: This does not preclude a faculty member from being reimbursed for expenses by their employer. This item limits only additional funding above reimbursements.
  • II. DECLARATION OF FINANCIAL INTERESTS OR RELATIONSHIPS:

    The ISMRM is committed to

    1. ensuring balance, independence, objectivity and scientific rigor in all Continuing Medical Education programs, and
    2. presenting CME activities that promote improvements or quality in healthcare and are independent of the control of commercial interests.

    As part of this commitment, the ISMRM has implemented a process in which speakers and everyone else in a position to influence the content of an education activity discloses all financial relationships with any commercial interest, of any amount within the last 12 months (click on links for definitions). In addition, should it be determined that a conflict of interest exists as a result of a financial relationshipand the content to be presented, this will need to be resolved prior to the activity.

    If you do not complete this form, whether or not you have relevant financial relationships, you will be disqualified from participating in the planning and implementation of this CME activity.

    Affiliations and financial interests disclosed will be indicated in program and syllabus listings and during each talk. ISMRM does not imply that such financial interests or relationships are inherently improper or that such interests or relationships would prevent the speaker from making a presentation. The intent is that any and all conflicts are identified, managed and disclosed to participants so that learners may form their own judgments about the presentation in the light of full disclosure of the facts.

    The declaration applies to any real or apparent financial interest or other relationship (i.e., grants, research support, consultant fees, honoraria, etc.) that the individual may have (or have had within the last 12 months) with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. This disclosure requirement extends to interests/financial relationships of spouses/partners. It does not apply to relationships with non-profit societies or governmental bodies.

  • INSTRUCTIONS

    First, indicate in the Declaration Statement whether or not you (or your spouse/partner) have had any financial interest or relationships with commercial interests within the past 12 months.

    Second, if you (or your spouse/partner) have financial interests, describe them under either:

    A) Grant and Research Support,

    B) Employment, or

    C) Other types of relationships.

    Give the names of relevant commercial entities. A drop-down list of some company names is provided. If the particular company does not appear on this list, please enter the name in the space provided. Relationships with non-commercial entities such as universities, hospitals, government agencies, foundations and non-profit societies are not to be included.

    For “Other types”, provide a description of the relationship, what was received, and the name of the company. Drop-down lists are provided. If your particular entry does not appear on these lists, please describe it in the spaces provided. The ISMRM does NOT want to know how much you received. Please do not provide the amount.

    Note: If you have more than one of a type of financial interest or relationship to disclose, please complete this form separately for each disclosure.

    A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The Accreditation Council for Continuing Medical education (ACCME) does not consider providers of clinical service directly to patients to be commercial interests.

  • DECLARATION STATEMENT:

  • A. GRANTS AND RESEARCH SUPPORT (choose from drop-down menu):

  • B. EMPLOYMENT (choose from drop-down menu):

  • C. OTHER TYPES OF FINANCIAL INTERESTS:

  • If you have another financial interest/relationship to disclose, please press "submit" and fill out the form again for each additional one.