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2019 AAPM&R Disclosure Form

American Academy of Physical Medicine and Rehabilitation Disclosure Form

1. Please provide current contact information below:

AAPM&R defines a "Direct Financial Relationship" as a relationship held by an individual that results in wages, consulting fees, honoraria, or other compensation (in cash, in stock or stock option or in kind), whether paid to the individual or to another entity at the direction of the individual, for the individual's service or expertise. The term "Direct Financial Relationship" does not mean stock ownership or intellectual property licensing arrangements and is for relationships from the past 12 months.

AAPM&R defines “Family member” as a spouse, domestic partner, parent, mother-in-law, father-in-law, child, spouse of child, grandchild, brother, sister, or spouse or child of a brother or sister. Guidelines relating to interests held by an immediate family member or extended family member shall apply to the extent such interests are known to the Trustee, Member or Senior Manager.
AAPM&R defines “Non-remunerative positions of influence” as unpaid/non-salaried roles such as officer, board member, trustee, spokesperson, consultant, advisor, reviewer, editor, or any such similar position.

The Council for Medical Specialty Societies (CMSS) defines a "Company" as a for-profit entity that develops, produces, markets, or distributes drugs, devices, services or therapies used to diagnose, treat, monitor, manage, and alleviate health conditions.

The Accreditation Council for Continuing Medical Education (ACCME) defines a "Commercial Interest" as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Note: Providers of clinical service directly to patients are not considered to be ACCME-defined commercial interests. For purposes of this disclosure form, please refer to the terms defined above.

Additionally, if you serve on any other organizations’ boards or committees, please disclose those as well.
2. Disclosures
***** When the questions below are marked with these asterisks, only volunteers in faculty and CME planning roles are required to answer them.
*This question is required.
My Positions of Influence and Direct Financial Relationships
Relationship Type Company/Commercial Interest/Affiliation Dollar/Range (for Board of Governors ONLY)
***** My Family Member's Positions of Influence and Direct Financial Relationships (to be answered only by volunteers who are serving as faculty or CME planners)
Relationship Type Company/Commercial Interest/Affiliation
3. Are you a member of the AAPM&R Board of Governors? *This question is required.
4. Disclosure Affirmations *This question is required.