Financial Relationship Disclosure Form

Disclosure of Relevant Financial Relationships

To help ensure integrity and independence in accredited continuing education (CE) activities, the Society for Neuro-Oncology (SNO) requires everyone in a position to control the content of an accredited CE activity must disclose all financial relationships with ineligible companies within the past 24 months to SNO. The Standards for Integrity and Independence in Accredited CE require that SNO disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited CE. SNO must mitigate relevant financial relationships and disclose these relevant financial relationships to participants prior to the beginning of the activity.

Mitigating Relevant Financial Relationships: Should SNO determine that a disclosed financial relationship(s) is relevant, SNO will begin a series of steps to mitigate the relevant financial relationship(s) based on the individual’s role in the activity and identify what, if any, action is necessary. The mitigation mechanism will identify potential bias and ensure content is aligned with interests of the learner. Only when the relevant financial relationship(s) has been mitigated may the individual participate in the activity.

First Name *

Last Name *

Email Address *

Affiliation *

CE Activity Title *

CE Activity Launch / Date (Date of your signature) *

Month

Day

Year

Definition: An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Instructions: Please disclose all financial relationships (any amount) that you have had in the past 24 months with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Disclosure *

Disclosure: Regarding my role in accredited CE activities (check one):

No, I have no personal financial relationship(s) with ineligible companies.

Yes, I have personal financial relationship(s) with ineligible companies. (Provide information below.)

What type(s) of financial relationships have you had in the past 24 months? *

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies. For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Have any of the above relationships ended? *

Yes

No

If any of the financial relationships existed during the last 24 months, but has now ended, please indicate this here: *

Please list the name of the company / companies with which you had the Employee financial relationship. *

Please list the name of the company / companies with which you had the Owner/Co-Owner, Founder/Co-Founder financial relationship. *

Please list the name of the company / companies with which you had the Consulting Fee (e.g., Advisory Board) financial relationship. *

Please list the name of the company / companies with which you had the Contracted Research financial relationship. *

Please list the name of the company / companies with which you had the Honoraria financial relationship. *

Please list the name of the company / companies with which you had the Speaker's Bureau financial relationship. *

Please list the name of the company / companies with which you had the Stock Shareholder financial relationship. *

Please list the name of the company / companies with which you had the Stock Options Holder financial relationship. *

Please list the name of the company / companies with which you had the Royalty financial relationship. *

Please list the name of the company / companies with which you had the Other financial relationship. Please define or describe the relationship. *

Validation Statements: SNO supports the validation of clinical content for all accredited CE activities. Please review the following statements and indicate your intent to comply with each expectation, by marking each statement that you are attesting. *

All recommendations for patient care in the activity, must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

All scientific research referred to, reported, or used in the activity, in support or justification of patient care recommendation, must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.

The content will not advocate for unscientific approaches to diagnosis or therapy, nor promote recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.

Signature & Attestation: By typing my name in the field below, I attest this disclosure is correct and complete and will provide any updates/changes to the status of this information to SNO, as soon as any changes occur.

Signature (Please type your First & Last Name) *

Today's Date *

(mm/dd/yyyy)

If you have any questions regarding the requirements, definitions or completion of this form, please contact MeLesa at melesa@soc-neuro-onc.org.

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Disclosure of Relevant Financial Relationships

Definition: An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.