COI Disclosure For speakers with a COI to declare

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Presentation transcript:

COI Disclosure For speakers with a COI to declare <First Name> <Last Name> … Lead Presenter: <First Name> <Last Name> Subject over the 3 year period prior to registration of the abstract. I have the following financial relationships to disclose. (for each, indicate “None” if not applicable.) 1. Leadership position/advisory role for: … Pharmaceutical Co., Ltd. 2. Stockholder in: … Pharmaceutical Co., Ltd. 3. Patents and royalties from: … Pharmaceutical Co., Ltd. 4. Honoraria (lecture fee) from: … Pharmaceutical Co., Ltd. 5. Manuscript fee from: … Pharmaceutical Co., Ltd. 6. Grant/Research funding from: … Pharmaceutical Co., Ltd. 7. Scholarship grants: … Pharmaceutical Co., Ltd. 8. Endowed chair: … Pharmaceutical Co., Ltd. 9. Other remuneration from: … Pharmaceutical Co., Ltd.