Abstract Form - Diabetes Pro - American Diabetes Association (Page 2 of 3) in pdf

Abstract Form - Diabetes Pro - American Diabetes Association Page 2

DISCLOSURE FORM

Research Symposium

Epigenetics and Epigenomics: Implications for Diabetes and Obesity

November 17-19, 2017

A. CONTACT INFORMATION

The information you provide will ensure the use of complete, accurate, and up-to-date information.

NAME and CREDENTIALS: ______________________________________________________________________

PROFESSIONAL TITLE(S): _______________________________________________________________________

INSTITUTION: ___________________________________________________________________________________

MAILING ADDRESS: _____________________________________________________________________________

PHONE: _______________

FAX: ______________________

EMAIL: _____________________

B. PRESENTATION INFORMATION

PRESENTATION TITLE: (Note: all titles must be approved by the activity planning committee)

_______________________________________________________________________________

LEARNING OBJECTIVE(S):

_________________________________________________________________________________________________

C. FINANCIAL RELATIONSHIPS

Please list below ANY financial relationships that you or your spouse/partner may have, involved in diabetes management and

treatment or its complications .

 1. Within the past 12 months, I have had NO financial relationships with any commercial interests, manufacturers

and/or proprietary entities. Proceed to question 3.

Abstract Form - Diabetes Pro - American Diabetes Association Page 2