Faculty Declaration Form

Please specify the event in which you are participating:*

If you are participating in an event not listed above, please specify:

What role(s) are you invited for?*

Organizer
Moderator
Speaker

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/BADGE INFORMATION

Name*

First Last

Institution*

Email*

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.

The content of CME activities does not promote the proprietary interests of any commercial interests.*

Yes, I agree.

Content of CME activities will be restricted to pure science (dealing with physics, chemistry and biology), industry issues and operation of devices, as opposed to the business lines or products of any commercial interest, and should not include any advertising, corporate logos, trade names or a product group message of an ACCME-defined Commercial Interest. If reference to product or company names is essential, it is subject to the guidelines below.*

Yes, I agree.

Syllabus contributions, abstracts, and other required documents will be submitted as specified.*

Yes, I agree.

All recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.*

Yes, I agree.

All scientific research referred to, reported or used in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection and analysis.*

Yes, I agree.

Unlabeled Uses of Products. When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity, the speaker is required to disclose that the product is not labeled for the use under discussion or that the product is still investigational.*

Yes, I agree.

Generic and Trade Names: Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If trade names must be used for clarification only, those of several companies should be used rather than only that of a single manufacturer.*

Yes, I agree.

Should there be a perceived conflict of interest regarding my presentation or involvement as an organizer, I agree to work with ISMRM to resolve the conflict as soon as possible prior to the presentation, activity or posting of educational materials.*

Yes, I agree.

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:

Check 1 OR 2 below, whichever applies to you; if you have checked 2 please describe financial interests/relationships in space provided.*

1. I do not have any financial relationships to report.
2. I have a financial interest/arrangement with one or more entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. (If you have checked “2”, report the names of companies/organizations and types of relationships below.)

Are the commercial entities with which you have relationships relevant to the content you are planning, developing or presenting for this activity?*

Yes, they are relevant
No, they are not relevant

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

1.

Other:

2.

Other:

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

Employment

Other:

C. OTHER TYPES OF FINANCIAL INTERESTS:

RELATIONSHIP (choose from drop-down menu):

Other:

WHAT WAS RECEIVED (choose from drop-down menu):

Other:

RECEIVED FROM (choose from drop-down menu):

Other:

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

III. PERMISSION TO RECORD:

Please check one:*

A. I give permission for my presentation to be recorded and made available to workshop registrants on the ISMRM website. I understand that the presentations will be password protected and accessible only to workshop registrants for one year after the workshop, and to ISMRM members for the second year after the workshop. In addition, I give permission for my presentation to be made available to the MRI radiographer and technologist community via the SMRT eLearning Center for future viewing. The presentations may be used for continuing education courses for SMRT.
B. I do not give permission for my presentation to be recorded and made available as described above.