Speaker's Resolution of Conflict of Interest

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

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

I will or have divested myself of this financial relationship. *

Yes

I will submit my talk in advance (PowerPoint Presentation) to allow for adequate peer review. *

Yes

I will recommend an alternative presenter for this topic for the planning committee's consideration *

Yes

I will refrain from making recommendations regarding products and/or services, e.g., limit presentation to pathology, diagnosis and/or research findings. *

Yes

I agree to support my presentation and clinical recommendations with the “best available evidence” from the medical literature. *

Yes

I attest that I will not accept any payment and/or reimbursement for this presentation directly from any commercial interest. I understand that all payments and/or reimbursements must be made by the authorized educational provider. *

Agree

Disagree

All scientific research referred to, reported or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection and analysis. *

Agree

Disagree

NOTE: Documentation of the mitigation strategies indicated above are required for participation in this educational activity. *

I will be using slides, scripts, and/or other treaching material provided by a commercial source. (If YES, please describe in next section). *

Yes

I will discuss a drug(s) and/or medical device(s) that has not been approved by the FDA. (If YES, please describe in next section). *

Yes

Slides, Scripts and/or Other Teaching Material Provided by a Commercial Source *

Unapproved FDA drug(s) and/or medical device(s) *

56th Annual World Congress-International College of Angiology: RESOLUTION OF CONFLICT OF INTEREST - All identified CONFLICTS OF INTEREST listed on the Speaker's Disclosure Form, will be resolved and disclosure will be made to activity participants.

TITLE OF PRESENTATION *

Email *

Date and time *

Name *

I AGREE TO: *

Promote quality or improvements in health care and not promote a specific proprietary business interest of a commercial entity.

Provide me presentation (or a working draft thereof) in advance of the educational activity. I understand that I may be asked to edit my presentation according to the Standards of Commercial Support.

Provide recommendations involving clinical medicine based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.

Provide appropriate peer-reviewed journal references which support clinical or practice recommendations. I understand that my presentation will be evaluated by participants for fair balance and I may be asked to edit accordingly.

Avoid the use of trade names in my presentation. If I determine that it is important to clarify via the use of trade names, trade names from all available companies will be included, not just trade names from a single company.

Disclose to the program audience when products/services are not labeled for the use under discussion or when the products are still under investigation.

Comply with patient confidentiality requirements as outlined in the Health Insurance Portability and Accountability Act (HIPAA).

PRESENTER/AUTHOR *

Resolution of Conflict of Interest

57th Annual World Congress

All identified Conflicts of Interest listed on the Speaker's Disclosure Form, will be resolved and disclosure will be made to activity participants.