Conflict of Interest Disclosure Form

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Conflict of Interest Disclosure Form EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS) EUROPEAN ACCREDITATIONCOUNCIL ON CME (EACCME®) Rue de l’Industrie 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30 https://eaccme.uems.eu - accreditation@uems.eu Conflict of Interest Disclosure Form (to be completed by scientific/organising committee members) NAME : AFFILIATION: In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement of expenses in relation to the LEE has been provided. DISCLOSURE q I have no potential conflict of interest to report q I have the following potential conflict(s) of interest to report Type of affiliation/ financial interest Name of commercial company Receipt of grants/ research supports Receipt of honoraria or consultation fees Participation in a company sponsored speaker‘s bureau Stock shareholder Spouse/ partner Other support (please specify) UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VATn° BE 0469.067.848 Signature: Date: