GPPA

Speaker Name *

Email Address *

Required entries with every submission*

FACULTY DISCLOSURE See Faculty Disclosure Statements

Individuals need to disclose relationships with a commercial interest if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CME about the products or services of that commercial interest.

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. The ACCME has not set a minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for you immediate family as defined above. If an individual is uncertain about what might constitute a potential financial conflict or interest they should err on the side of full disclosure.

Category	Code	Description
Consultant / Advisor	C	Consultant fee, paid advisory boards or fees for attending a meeting (for the past 1 year)
Employee	E	Employed by a commercial entity
Lecture Fees	L	Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial entity (for the past 1 year)
Equity Owner	O	Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial psychiatric products or commercial psychiatric services
Patents / Royalty	P	Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant Support	S	Grant support for the past 1 year (all sources) and all sources used for this project if this form is an update for a specific talk or manuscript with no time limitation.

Please select one of the following two options

I DO NOT have any financial relationship to disclose.

I have the following financial relationships to disclose:

Company/Organization:

Code(s): C E L O P S

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation (specify drug(s) or product(s) by name for which the unlabeled use will be discussed.

I have read the Disclosure Requirements and to the best of my knowledge, the information provided on this form is true and correct and represents all items for disclosure. I understand that failure to comply with the disclosure policy, when known and deliberate, may result in disqualification for two years in similar educational or related activities. I agree to promptly notify the program directors is any of this information changes.

Entering your name in the following space acts as my signature and agreement to the above statement:

PLEASE NOTE: AFFILIATIONS LISTED ON THE DISCLOSURE FORM MUST ALSO BE LISTED ON YOUR PRESENTATION, ON THE PAGE JUST AFTER THE TITLE PAGE, PER ACCREDITATION "FIRST SLIDE" POLICY.