ANS ABSTRACT Conflict of Interest/Disclosure Form - 2025

COI Disclosure form ~ ANS 60th Annual Spring meeting
May 16-17, 2025
New Orleans, LA

In order to complete Part I of the ANS Abstract submission process, as the Primary author, please complete the following Conflict of Interest/Disclosure form as it relates to you as the primary author. If you are not the presenter, you will be required to complete a COI/DISCLOSURE for the presenter as well. Co-authors (non speaking roles) are NOT REQUIRED to fill out a COI/DISCLOSURE form.

You Must Indicate ONE of the Following when Submitting Your Abstract.

ORAL (will be considered for ORAL presentation only)
POSTER (will be considered for POSTER presentation only)
EITHER (Selecting this category does not lessen your chances of being selected for an ORAL presentation)

The preferred method of presentation (ORAL or POSTER) should be noted. If you select EITHER, the ANS Scientific Program Committee will make the final determination as to where to place your abstract. The same submission rules apply for both POSTER and ORAL submissions. In order to be considered for an award, the abstract must first be selected by the Scientific Program Committee as an ORAL presentation, (you may submit as ORAL or EITHER).

ABSTRACT TITLE: Please choose your title carefully. Changes to titles will not be accepted once your abstract is selected for presentation.

Upon successful completion of the COI/Disclosure form, you will be automatically directed to the ANS Abstract submission form. Your abstract submission will be sent electronically to the ANS Administrative Office. You will receive a confirmation email once your abstract has been received.

THANK YOU FOR YOUR COMPLIANCE!
Kristen Bordignon
Cheryl Bradley

ANS Administrative Team

FROM THE AMERICAN COLLEGE OF SURGEONS, THE ACCREDITED PROVIDER:

In accordance with ACCME regulations (ACCME Standard 3), the American College of Surgeons must ensure that anyone who is able to control the content of the activity has disclosed all financial relationships with any ineligible companies in the 24 months prior to their involvement in the educational activity.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME system (ineligible companies) are those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.

Financial Relationships: Financial relationships are relevant if the following three conditions are met for the individual who will control content of the education: 1) a financial relationship, in any amount, exists between the person in control of content and an ineligible company; 2) the financial relationship existed in the last 24 months; 3) the content of the education is related to the products of an ineligible company with whom the person has a financial relationship.

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.

All CME Planners and Speakers /Moderators/Discussants/Authors/Editors involved in the development and/or presentation of CME content must complete this form. If applicable, the first author is responsible for collecting and submitting disclosure information on behalf of the presenter if different. The form must be updated whenever circumstances require. In addition, all affirmative disclosures for speakers must be revealed by a slide at the beginning of the presentation.

Failure or refusal to disclose or the inability to manage the identified conflict will result in the withdrawal of the invitation to participate.

Question Title

* 1. Please complete the following:

Full Name: *

Address 1: *

Address 2:

City/Town: *

State/Province:

ZIP/Postal Code: *

Country:

Email Address: *

Cell Phone (preferred)

Question Title

* 2. Title of Abstract: (must match EXACTLY with your Abstract submission title, think carefully, changes to titles are not permitted once submitted.) TRADE NAMES ARE NOT PERMITTED WITHIN THE TITLE when a GENERIC TERM is available.

Question Title

* 3. What is your role in this CME Activity: (Check all that apply)

Primary Author

Panelist

Guest Lecturer

Moderator

Administrative Staff

Scientific Program Committee

Education Committee

Executive Council Member

Co-Author/Presenter

Question Title

* 4. I disclose the following:

I DO NOT HAVE personal financial relationships with any ineligible companies that pertain to the content of my presentation.

I DO HAVE relevant financial relationship(s) with ineligible companies that pertain to the content of my presentation. (please list in box below)

1. List the names of companies that you have a financial relationship with currently or have had in the last 24 months.

2. Specify your role (i.e., consultant, board member, etc.)

3. Explain what you received (i.e., salary, honorarium etc.)

4. If equity was received, designate if it is public or privately traded (only if applicable)

If you selected "I do have financial relationship..."

List all financial relationships with commercial interests as follows:
John S. Parker, MD
Cochlear America- Consultant-honorarium
Advanced Bionics - Surgical Advisory Board-Travel

If it is determined that a conflict of interest exists as a result of a financial relationship you have, you will be contacted and methods to manage the conflict will be discussed with you.

Question Title

* 5. I have disclosed to the ANS all relevant financial relationships, and I will disclose this information to learners verbally for live activities and in print.

Yes

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* 6. I agree that I will not directly accept honoraria, travel expenses, in-kind contributions, or any other support from commercial companies in connection with this activity.

Agree

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* 7. If any of the information reported above changes, I will notify ANS immediately and update this form accordingly.

Agree

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* 8. By checking this box I confirm this abstract is exclusive to ANS and I will NOT submit it to any other participating COSM society, this includes AOS. I understand that a duplicate submission to ANS & AOS will disqualify my abstract from both Societies.

I have not submitted this abstract to another Society

Question Title

* 9. As the PRIMARY AUTHOR, I certify that I have identified and disclosed all financial relationships with any ineligible companies (in the last 24 months) and that all information provided herein is true and correct.

Agree

Question Title

* 10. I am the primary author and presenter.

Yes