SUN Early Registration Deadline - January 31, 2017

SUN Abstract Deadline - March 15, 2017

SUN Meeting Cape Town July27-31st, 2017

Johannesburg/Game reserve July 31st-August 3, 2017

2017 South Africa Disclosure Form   

Important!!! You will be able to upload your PowerPoint Presentation at the bottom of the form. 

Name *
Name
Phone *
Phone
AANS Disclosure of Financial Relationships.
Activity/Date: JULY 27TH–AUG 3RD, 2017
ACCME’s Updated Standards for Commercial Support requires that anyone in a position to control the content of the educational activity has disclosed all financial relationships with any 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. Failure or refusal to disclose or the inability to satisfactorily resolve the identified conflict may result in the withdrawal of the invitation to participate in any AANS education activities.
Check one *
(A) List the names of proprietary entities producing, marketing, re-selling, or distributing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner/co-author have, or have had, a financial relationship within the past 12 months. For the purpose of this disclosure, ACCME considers the financial relationships of your spouse/partner/co-author to be included as yours. Clarify what you or your spouse/partner/co-author received (ex: salary, honorarium, stock, etc) specify the company name next to your role with the company below. (B) Clarify what you or your spouse/partner/co-author received (ex: salary, honorarium, stock, etc) specify the company name next to your role with the company below.
Type the company name in the text box below. Must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Cannot leave blank, must type N/A if not applicable
Commercial Interest The CCME defines a "commercial interest" as any proprietary entity producing health care goods or services consumed by, or used on, patients. 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 he/she has a financial relationship. Financial relationships The ACCME defines "financial relationships" as those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (i.e., 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 and/or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse/partner. Relevant financial relationships The ACCME defines "relevant financial relationships" as those relationships in any amount occurring within the past 12 months that create a conflict of interest. ACCME focuses on financial relationships with commercial interests in the 12-month period preceeding 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.
**Failure or refusal to disclose or the inability to satisfactorily resolve the identified conflict will result in the withdrawal of the invitation to participate.