Conflict of Interest Disclosure Form

Salutation

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Name of the individual

Title

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Specialty

Corresponding Address

Email Address

This email address will be used to confirm your enrollment

Cell Phone

Name of the scientific event for which I am submitting this form?

If San DIego Convention Sep 2023: New Wave Medicine. If Egypt Convention Dec 2023: Practicing Medicine in an Era of Healthcar.

My role is (select all that apply)

Planner

Speaker

Moderator

Other: (Specify):

Disclosure of Financial Relations:

As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence.

Please complete the form below.

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance.

If you have questions, please contact us at naama@naama.com

Disclosing Financial Relationship in the past 24 months (Enter none across the first row if not applicable)

	Enter the Name of Ineligible Company.	Role: Enter the Nature of Financial Relationship	Has the Relationship Ended? Answer only - YES/ NO
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Please read the description below before completing this table

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards)

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

If the financial relationship existed during the last 24 months but has now ended, please check the box in this column below. This will help the education staff determine if any mitigation steps need to be taken.

Declaration (if applicable): In the past 24 months, I have not had any financial relationships with any ineligible companies.

Signature: Please use the mouse to sign your name

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Today's Date

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I attest that the above information is correct as of this date of submission.