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.

EAST's CME partner is the American College of Surgeons (ACS).  EAST must comply with all ACS requirements, including financial disclosure. 

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.

Glossary of Terms

Commercial Interest - A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.  The ACCME does not consider providers of clinical service directly to patients to be commercial interests.

Financial relationships - Financial relationships are those relationships in which the individual benefits by receiving a 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.  Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.  ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant financial relationships - ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant.  Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of Interest - When an individual’s interests are aligned with those of a commercial interest the interests of the individual are in ‘conflict’ with the interests of the public. The ACCME considers financial relationships to create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest. The potential for maintaining or increasing the value of the financial relationship with the commercial interest creates an incentive to influence the content of the CME – an incentive to insert commercial bias.

YOU MUST COMPLETE ALL INFORMATION BELOW AND THE ATTESTATION.


Survey Submitter Information


Financial Disclosure Information

List details/type of interest/arrangement being disclosed

Attestation - See below for full attestation statement

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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.