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2019 TANS Speaker Disclosure Form
The intent of this disclosure is to allow Texas Medical Association the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its CME activities. All faculty and planners of TMA-sponsored activities are expected to disclose to TMA any relevant financial relationships with any commercial interest that produces health care goods or services concerned with the content of an educational presentation.

Conflict of interest. Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which she/he has a financial relationship.

Commercial interest. Any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.

Financial relationships. 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, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.

Email address *
Name of Speaker *
Your answer
Title of Presentation: *
Your answer
Do you have relevant financial relationships with proprietary entities producing health care goods or services related to the content of this activity? *
If YES, please identify the company and nature of the relationship below.
What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, grant, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, research, membership on advisory committees or review panels, board membership, and ‘other activities (please specify).

Company Name (ex. XYZ Company)
Your answer
What was received? (ex. honorarium)
Your answer
For What Role? (ex: a speaker)
Your answer
Electronic Signature
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