EAST Research Related Surveys - Conflict of Interest Disclosure Form

The Eastern Association for the Surgery of Trauma (EAST) requires financial disclosure information for all solicitations of the EAST membership for research related purposes be obtained even if there is nothing to disclose.

Survey submitters are required to complete this form (scroll to bottom of the page for the form) indicating financial disclosure status. Failure to accurately report financial disclosure information may result in sanctions for future solicitations of the EAST membership for research related purposes.

Complete all disclosure information (even if nothing to disclose) and the attestation. If there is anything to disclose please complete the information as prompted.

List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
Explain what is received (ex: salary, honorarium etc.) and specify the author's role.
What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.
The Survey Submitter's Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

YOU MUST COMPLETE ALL INFORMATION BELOW AND THE ATTESTATION.

Survey Submitter Information

Full name*

Email Address *

Survey Title*

Financial Disclosure Information

You must check one box*

No financial interest to disclose for all individuals on this survey request.
Yes, financial interest to disclose as it relates to this survey request. Provide details below.

Financial interest/arrangement or affiliation being disclosed

List details/type of interest/arrangement being disclosed

Attestation - See below for full attestation statement

Date*

mm/dd/yyyy

I attest that the information provided above is accurate and complete*

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I acknowledge that I have read the Eastern Association for the Surgery of Trauma (EAST) requirements for disclosure of relevant financial relationships and hereby attest that the relationship(s) with commercial interests I have duly disclosed will not influence or bias the solicitation of the EAST membership for research related purposes. I will adhere to the principle that information presented to the EAST membership must be unbiased, scientifically balanced, and based on best evidence and best practices in medicine, and I agree to disclose when products/services are not labeled for the use under discussion or when the product/service is still under investigation. I understand that the information I have listed on this form will be shared with the EAST Research-Scholarship Committee. In addition, I or any individuals involved with this solicitation of the EAST membership for research related purposes listed: a.) will not accept honorarium, travel expenses, in-kind contributions, or any other support from commercial companies in connection with this); b.) agree to obtain all necessary copyright permissions; And c.) attest that the material is HIPPA compliant. In addition, if any time after submitting this form the financial relationships change for myself those of my fellow colleagues, I will provide the information to EAST in writing prior to distribution of the survey if approved by the EAST Research-Scholarship Committee and they will be reflected in the verbal and written materials.