1. 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.