Thank you for filling out the IAFP CME Disclosure Form. Click the link below to view our CME disclosure policy: 

Question Title

* 1. Please fill out the form below:

Question Title

* 2. I acknowledge that I have received a copy of the IAFP CME Disclosure Policy and that I have read, understand and agree to comply with the Policy.

Question Title

* 3. Please check all appropriate IAFP activities:

Question Title

* 4. Disclosure of all financial relationships with ineligible companies within the prior 24 months of the completion date of this form:

Ineligible companies are those who primary business is producing, marketing, selling, re-selling, or distributing health care products used by, or on patients.

Question Title

* 5. Please complete for all relationships that apply.

*Relationship types including but not limited to employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

Question Title

* 6. Attestation and Signature
I have read and understand the IAFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether this relationship precludes my participation, and I may be asked to provide additional information. I understand that it is necessary to update disclosure information should my status change during the course of the CME activity.
I understand that failure or refusal to disclose, false disclose, or inability to resolve conflicts of interest will disqualify me from participating in this activity.

Please type your name here; we will treat this as your signature:

Question Title

* 7. Date:

Date
Thank you for completing the IAFP Disclosure Form. This disclosure is valid for one year, but should you have relevant changes within the year, please notify IAFP staff. You will be contacted by a IAFP staff member if there are questions pertaining to your disclosure.

T