Planning Committee Member Conflict of Interest Disclosure Statement

Below are two date fields that represent a range –start date and end date.  You will be specifying a range of proposed dates - for example between January 1st and January 30th.

  • Please use the first date field to specify a proposed start date. This will be the earliest recommended / proposed date – the beginning of a range of dates.
  •  Then use the 2nd date field to specify a proposed end date (the end of a range of dates)

Note: if you only want to provide one specific date, then please enter this in the Proposed Start Date Range field and ignore the end date.

MM/DD/YYYY

MM/DD/YYYY

The following must be provided:
*If, in the past 12 months you or your spouse/partner, or immediate member of your family have had a beneficial financial relationship/arrangement or affiliation (activities for which remuneration is received or expected) with one or more commercial organizations that could be perceived as a real or apparent conflict of interest, you MUST select the corresponding Yes box and provide the information. A commercial interest is defined as a proprietary entity producing health care goods and services, (with the exception of non-profit or government organizations).
Disclosure Name of Commercial Interest(s):
NoYes
Remuneration (Speaker's Bureau, honoraria, travel expense, etc)
Consultant fees
Grant/Research Support
Major Stock/Shareholder (not mutual funds)
Advisory Board
Ownership or Partnership
*If you check "Yes" in any box above, you must provide the name of the Commercial Interest.
 
 
 
 
Note: Each planning committee member must also submit their CV to the
Office of Continuing Medical Education, Box 70572, Johnson City, TN 37614-0572 through our Fax number (423)439-8040 or by emailing  johnsonc@etsu.edu
 
 
Click on the Submit button below to complete this application process.
 
You will receive an e-mail confirmation within 24-hours of receipt of submission. 
 
You may print a summary of your responses for your records from the next screen. 
 
Thank you.

 

Revised 04-09-09