Conflict of Interest Disclosure Sample

This is only a sample. You will fill out the real form later in the submission process.

THE FOLLOWING INFORMATION IS REQUIRED FOR PRESENTERS ONLY

Disclosure Information for Presenters at the

All presenters are expected to disclose to the audience any significant financial interest or other relationship (1) with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation and 2) with any commercial supporters of the activity. This disclosure should cover relationships that are in place at the time of and/or 12 months preceding the activity. Significant financial interest or other relationship may include grants or research support, or being an employee, consultant, major stock holder, or member of speakers bureau, etc. The intent of this disclosure is to provide the audience with information on which they can make their own judgments to determine whether the speaker's interests or relationships may influence the presentation with regard to exposition or conclusion.

  1. Do you have any significant financial interest or other relationship
    with a commercial supporter of this activity?
    Yes    No

    Commercial Supporters of this Activity are:
    The CDC Foundation
    The Task Force for Child Survival and Development

    If Yes, name the commercial supporter and describe the nature of the relationship(s).


  2. Will your presentation include any discussion of commercial products or services (including nonprofit services of any organization supporting this activity)?
    Yes    No     (If yes, answer questions A & B below)

    A. If Yes, do you have a significant financial interest or other relationship
    with the manufacturer(s) of any of the products or provider(s) of any of the services you will discuss?
    Yes     No

    B. If Yes, please list the manufacturer(s) or provider(s) and describe the nature of the relationship(s).


  3. Will your presentation include any discussion of unlabeled use of a commercial product, or a product for investigational use?
    Yes    No

    If Yes, please describe the product and the unlabeled or investigational use.