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Financial Disclosure Forms

As an individual who has the ability to impact the overall operations and/or finances of the Organization for Human Brain Mapping, we ask that you complete a financial disclosure. Even if you have no disclosures, you are still required to complete the form. 

Name: *
Last Name: *
Company/Institution: *
Do you, your spouse or partner, have any relevant financial relationships with any commercial interests? *

Clear Selection
First, list the names of any commercial interest defined as any entity producing, marketing, re-selling or distributing health care goods or services, consumed by, or used on, patients, with the exemption of non-profit or government organizations and non-health care related companies with which you, your spouse or partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
Second, describe what you or your spouse/partner received (ex: salary, honorarium etc). The OHBM does NOT want to know how much you received.
Third, describe your role(s)(e.g. Speaker)
Are you or your spouse/partner an employee of or have financial interest such as shares in any commercial interests? If yes, complete the information below: *

Clear Selection
If yes, please explain below how you or your spouse/partners employment will affect your presentation:

Example terminology

What was received
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.

Role(s)
Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and ‘other activities (please specify).

Glossary of Terms

Commercial Interest
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.”

Financial relationships
Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria for promotional speakers' bureau, 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 from 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.

Relevant financial relationships
ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of Interest
Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

By clicking 'yes', I am approving all information entered above is accurate: *

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