2024 Workshop Disclosure Form

2024 ISMRM Workshop
Disclosure Form

"*" indicates required fields

Full Name*

Including credentials

Degree(s)*

Institution*

Please specify the event in which you are participating:*

What role(s) are you invited for?*

Organizer

Moderator

Speaker

Purpose: The information you provide addresses requirements of the Accreditation Council for Continuing Medical Education (ACCME) to help ensure integrity and independence in accredited Continuing Education (CE) activities. Everyone in a position to control the content of an accredited CE activity must disclose all financial relationships with ineligible companies, within the past 24 months (whether the relationship has now ended or is currently active) to the ISMRM. The Standards for Integrity and Independence in Accredited CE require that ISMRM disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited CE. ISMRM must mitigate relevant financial relationships and disclose these relevant financial relationships to participants prior to the beginning of the activity.

Definition: An ineligible company is any entity whose primary business is producing marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Instructions: Please disclose all financial relationships (any amount) that you have had in the past 24 months with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Disclosure*

Regarding my role in accredited CE activities (check one)

No, I have no financial relationship(s) with ineligible companies.

Yes, I have financial relationship(s) with ineligible companies.

Nature of Financial Relationship*

Check all that apply

Employee

Owner/Co-Owner

Founder/Co-Founder

Consulting Fee (e.g., Advisory Board)

Contracted Research (Must provide information, even if received by the institution)

Honoraria

Speakers’ Bureau

Stock Shareholder (Individual stocks; diversified mutual funds do not need to be disclosed)

Stock Options

Royalty

Other

Employee - Name of Company(s)*

Owner/Co-Owner - Name of Company(s)*

Founder/Co-Founder - Name of Company(s)*

Consulting Fee - Name of Company(s)*

Contracted Research - Name of Company(s)*

Honoraria - Name of Company(s)*

Speakers’ Bureau - Name of Company(s)*

Stock Shareholder - Name of Company(s)*

Stock Options - Name of Company(s)*

Royalty - Name of Company(s)*

Other - Name of Company(s)*

Describe nature of financial relationship

Has one or more of the above relationships ended?*

Yes

If the financial relationship existed during the last 24 months, but has now ended, please indicate this below*

Mitigating Relevant Financial Relationships: Should ISMRM determine that a disclosed financial relationship(s) is relevant, ISMRM will begin a series of steps to mitigate the relevant financial relationship(s) based on the individual’s role in the activity and identify what, if any, action is necessary. The mitigation mechanism will identify potential bias and ensure content is aligned with interests of the learner. Only when the relevant financial relationship(s) has been mitigated may the individual participate in the activity.

Validation Statements: ISMRM supports the validation of clinical content for all accredited CE activities. Please review the following statements and indicate your intent to comply with each expectation.

All recommendations for patient care in the activity, must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.*

Yes, I agree.

All scientific research referred to, reported, or used in the activity, in support or justification of patient care recommendation, must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.*

Yes, I agree.

The content will NOT advocate for unscientific approaches to diagnosis or therapy, nor promote recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.*

Yes, I agree.

All published material and attributable work is appropriately cited.*

Yes, I agree.

Permission to Record

Please check one:*

I give permission for my presentation to be recorded and made available to workshop registrants on the ISMRM website. I understand that the presentations will be password protected and accessible only to workshop registrants for one year after the workshop, and to ISMRM members for the second year after the workshop. In addition, I give permission for my presentation to be made available to the MRI radiographer and technologist community via the ISMRT eLearning Center for future viewing. The presentations may be used for continuing education courses for ISMRT.

I do not give permission for my presentation to be recorded and made available as described above.

Signature & Attestation*

By typing my full name, I attest this annual disclosure is correct and complete and will provide any updates/changes to the status of this information, promptly.

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