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Faculty/Presenter Disclosure Slide 1
Speaker Name: Please choose the statement that best describes your disclosure: I have no relationships with for-profit or not-for-profit organizations. OR Relationships with for-profit or not-for-profit organizations Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd. Consulting Fees: MedX Group Inc. Other: Employee of XXY Hospital Group
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Disclosure of Financial Support Slide 2
This session/program has received financial support from [enter for-profit or not-for-profit organization] in the form of [describe support here – e.g. an educational grant]. This session/program has received in-kind support from [enter for-profit or not-for-profit organization] in the form of [describe support here – e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this
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Mitigating Potential Bias Slide 3
[Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document.
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