Abstract Conflict of Interest & Disclosure Form

THE FOLLOWING FORM MUST BE SUBMITTED WITH YOUR ABSTRACT IN ORDER TO BE CONSIDERED FOR PRESENTATION

ABSTRACTS NOT COMPLYING WITH THE INFORMATION BELOW WILL NOT BE CONSIDERED

Please read the information entirely prior to completing the form.

I have read the policies regarding "Conflict of Interest" and "Off-Label Disclosure" relative to the presentation as submitted and titled below:

Presenting Author's Full Name *

Off-Label Disclosure *

This presentation DOES NOT include information about product(s) not labeled for use or investigational.

This presentation DOES include information about procedure(s)/product(s) not labeled for use and/or are investigational. I understand that I must disclose this information to the audience prior to the presentation.

Contact Us

Executive Office:

International College of Angiology

161 Morin Drive

Jay, Vermont 05859-9283 USA

Tel: +802.988.4065

Fax: +802.988.4066

Email: ica@intlcollegeofangiology.org

Conflict of Interest: A potential conflict of interest exists when there is involvement between the speaker/presenter with any for-profit commercial form or organization (FPC). This includes, but is not limited to, one or more of the following: consultant, scientific advisory committee member, or lecturer for a FPC from which income is derived; officer, board member, trustee, owner or employee of an FPC; stock or bond holdings in an FPC (investments entirely managed by a third party such as mutual funds and pension plans are excluded); stock options held in an FPC.

Off-Label Disclosure (Including Generic Trade Names and Reporting Scientific Research): Presentations must give a balanced view of options. Faculty use of generic names will contribute to this impartiality. Presentations supported by any commercial entity reporting the results of scientific research must conform to the generally accepted standards of experimental design, data collection and analysis. When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is being discussed during an educational activity, it is required that the speaker disclose that the product is not labeled for the use under discussion or that the product is still investigational.

The Importance of Identification: In order for the audience at a presentation sponsored by the International College of Angiology to evaluate information, analysis and opinions presented during the meeting, it is crucial that the audience be informed of any aspect of the speaker's personal or professional affiliations that may reasonably affect the presenter's view prior to the presentation(s). (For instance, affiliation with the manufacturer of a drug or device related to the topic). Additionally, faculty members are required to report if their presentation includes discussion(s) of investigational products or products not labeled for use.

Presentation Title *

Nature of Conflict (be specific): *

In submitting the above information, I acknowledge all to be complete to the best of my knowledge, and by completing the form below, this will serve as my signature to same.

Yes

No (if no, please explain)

To the best of my knowledge: *

I DO NOT have a Conflict of Interest

A Conflict of Interest DOES EXIST. I understand that it is necessary that the conflict be identified openly at the beginning of my presentation so that the audience may form their own judgments about the presentation with the full disclosure of the fact of my presentation.

Date and time *

Off-Label Procedure(s)/Product(s) under investigation include: *

International College of Angiology

Member, Council for International Organizations of Medical Sciences (CIOMS)

EXECUTIVE OFFICE: 161 MORIN DRIVE, JAY, VERMONT 05859-9283 U.S.A.
TELEPHONE: +802.988.4065 FAX: +802.988.4066
ICA EMAIL: denisemrossignol@cs.com or ica@intlcollegeofangiology.org

CONFLICT OF INTEREST & OFF-LABEL DISCLOSURE POLICIES & FORM

ABSTRACT PROCESSING FEE: A one-time non-refundable abstract processing fee of USD $25 must accompany your abstract submission for Non-Fellows of the International College of Angiology. Those who are Fellows, Associate/Affiliate Fellows, Members and Students of the ICA receive a waiver of this fee as part of their membership benefits. Please refer to the "Online Abstract Processing Fee" section for the payment of your ABSTRACT PROCESSING FEE. Thank you.