Name *

First Name

Last Name

Phone *

Country

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The AANS requires that the content of CME activities provide balance, independence, objectivity, and scientific rigor. Planning must be free of the influence or control of a commercial entity, and promote improvements or quality in healthcare. In addition, the content or format of a CME activity and its related materials must promote improvements or quality in healthcare and not a specific proprietary commercial interest. All AANS CME activities must be compliant with the ACCME content validation statements: All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, and analysis. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the CME educational material or content includes trade names, trade names from several companies should be used and not just trade names from a single company. Educational materials that are part of a CME activity such as slides, abstracts, and handouts cannot contain any advertising, trade names without generic names (but listing of trade names from several companies is permissible), or product-group advertising. Any individual refusing to comply with this policy and/or not disclosing relevant financial relationships annually will not participate in, have control of, or responsibility for, the development, management, or presentation, of AANS CME activities. *

I have read and I understand and agree with the statements above

I have read and I understand, but do not agree with the statements above (you will be contacted by an AANS staff member)

ACCME’s Standards for Integrity and Independence in Accredited Continuing Education requires that anyone in a position to control the content of the educational activity has disclosed all financial relationships with any ineligible company. The ACCME defines an ineligible company as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Failure or refusal to disclose or the inability to satisfactorily resolve the identified conflict may result in the withdrawal of the invitation to participate in any AANS education activities. This disclosure form is now linked to The Society of University Neurosurgeons speaking engagements, you need to disclose all financial relationships. Please indicate your financial relationships by checking the appropriate box below: (PLEASE NOTE: This disclosure is valid for 24 months...please update as needed) *

I do not have any financial relationships with any commercial interests.

I do have financial relationships with commercial interests which I will disclose.

List the names of proprietary entities producing, marketing, re-selling, or distributing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you have, or have had, a financial relationship within the past 24 months. Please select N/A to any that do not apply. Question Title * University Grants/Research Support *

N/A

Company

Industry Grant Support *

N/A

Company

Consultant Fee *

N/A

Company

Stock or Shareholder *

N/A

Company

Honorarium *

N/A

Company

Speaker's Bureau *

N/A

Company

Employee (any industry) *

N/A

Company

Fiduciary Position (of any organization outside the AANS) *

N/A

Company

Other Financial or Material Support *

N/A

Company