PSR17237 - ISIPT Conference 2017 - Presenter Disclosure Declaration Form

It is the policy of the University of Toronto, Faculty of Medicine, Continuing Professional Development to ensure balance, independence, objectivity, and scientific rigor in all its individually accredited or jointly accredited educational programs. Speakers and/or planning committee members, participating in University of Toronto accredited programs, are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships within the last FIVE (5) years with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of facts. It remains for the audience to determine whether the speaker’s outside interests may reflect a possible bias in either the exposition or the conclusions presented.

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* 1. Abstract Number:(if known and applicable)

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* 2. Please enter your full name (as the main contact for the workshop):

First Name

Last Name

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* 3. Please enter your email address:

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* 4. Please complete the disclosure below:

The presenter(s) has/have NO actual or potential conflict of interest in relation to this program.

Yes, one or more of the presenters HAS / HAD financial interest, arrangement or affiliation with one or more organizations that could be perceived as a related or apparent conflict of interest in the context of the subject of this presentation over the past FIVE (5) years.

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* 5. If yes, please specify company/organization name (e.g. Grant/Research Support: Merck, SSHRC)

Grant / Research Support:

Consultant:

Speakers’ Bureau:

Major Stock Shareholder:

Other Financial / Material Support:

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* 6. Disclosure of Investigational Use or "Off-label" Use of Medical Devices, Products, or Pharmaceuticals

If you will discuss or describe "off-label" products, you are responsible for disclosing this information to the audience at the beginning of your presentation.

I WILL discuss or describe in my presentation at the meeting the investigational or unlabelled ("off-label") use of a medical device, product, or pharmaceutical that is classified by Health Canada as investigational for the intended use.

I WILL NOT discuss or describe in my presentation at the meeting the investigational or unlabelled ("off-label") use of a medical device, product, or pharmaceutical that is classified by Health Canada as investigational for the intended use.

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* 7. Please indicate if you are participating in this
continuing education event as:

a planning committee member

an invited speaker

an abstract presenter

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* 1. Abstract Number:(if known and applicable)

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* 2. Please enter your full name (as the main contact for the workshop):

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* 3. Please enter your email address:

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* 4. Please complete the disclosure below:

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* 5. If yes, please specify company/organization name (e.g. Grant/Research Support: Merck, SSHRC)

Question Title

* 6. Disclosure of Investigational Use or "Off-label" Use of Medical Devices, Products, or PharmaceuticalsIf you will discuss or describe "off-label" products, you are responsible for disclosing this information to the audience at the beginning of your presentation.

Question Title

* 7. Please indicate if you are participating in this continuing education event as:

* 6. Disclosure of Investigational Use or "Off-label" Use of Medical Devices, Products, or Pharmaceuticals

If you will discuss or describe "off-label" products, you are responsible for disclosing this information to the audience at the beginning of your presentation.

* 7. Please indicate if you are participating in this
continuing education event as: