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2021 ASPHO Review Course Speaker Information

1. Contact Information
This question requires a valid email address.
2. Disclosure of Relevant Financial Relationships
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support, all planners, faculty (presenters and moderators), reviewers, and any others involved in the development of CME content are required to disclose to ASPHO all relevant financial relationships. An individual has a relevant financial relationship if he or she and/or their spouse/partner has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services may be discussed in the CME activity content over which the individual has control. Relevant financial relationships will be disclosed to the activity audience. ASPHO will disqualify all individuals who refuse to provide information on their relevant financial relationships. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Do you and/or your spouse/partner have any relevant financial relationships with any commercial interests?   
*This question is required.
If yes, list the the name(s) of the commercial interests and nature of the relationship(s) and below.

Commercial interest (ex: company X)
What was received? (ex: honorarium)
For what role? (ex: speaker)

If you have additional disclosures to provide, but not enough space, please email Cassie McGarigle.
Space Cell Commercial InterestWhat was received?For what role?
3. Is off label use of a drug or product addressed in this presentation? *This question is required.