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

Abstract Form - Diabetes Pro - American Diabetes Association Page 3

 2. Within the past 12 months, I have had financial relationships with commercial interests, manufacturers, and/or

proprietary entities. Please check the following relationships, which will be disclosed to the audience are:

Speaker’s

Commercial Interest

Research

Employee

Board

Stock/

Consultant

Other

Received monies

(Name of Company)

Support

Bureau

Member/

Shareholder

greater than

Advisory Panel

$10, 000 per

company

Explain “Other” Relationship ________________________________________________________________________________

 3. In my role with this activity, I agree to abide by the following Content Validation Statements with regard to any

recommendations for clinical care:



All recommendations involving clinical medicine are based on evidence accepted within the profession of medicine as

adequate justification for their indications and contraindications in the care of patients; AND/OR



All scientific research referred to or reported in support or justification of a patient care recommendation conforms to

generally accepted standards of experimental design, data collection, and analysis.

 4. In my role with this activity, I will ensure that my presentation will be independent, balanced, objective and

scientifically rigorous.

 5. I agree to abide by the standards of commercial support guidelines in that my poster presentation will ONLY

include generic names of drugs and not include use of company names/logos.

 6. I agree that my presentation will address at least one of the IOM or ACGME/ABMS core competencies.

____________________________________________

_______________________

SIGNATURE

DATE

A separate disclosure form must be completed by ALL authors and returned to:

Shirley Ash, American Diabetes Association, 2451 Crystal Drive, Suite 900, Arlington, VA 22202

Phone: 703-549-1500, x2214  Fax: 703-253-4358  E-mail:

Abstract Form - Diabetes Pro - American Diabetes Association Page 3