sample form

Collect the following information from each abstract author.
Enter this information in the online system during abstract submission.
Continuing Medical Education (CME) Conflict-of-Interest Disclosure Form
The American Society of Hematology (ASH) is committed to ensuring the integrity of its
scientific, educational, and research programs. The ASH Conflict of Interest Policy
requires disclosure of any financial or other interest that might be construed as resulting
in an actual, potential, or apparent conflict.
ASH’s Conflict of Interest Policy along with rules formulated by the Accreditation
Council for Continuing Medical Education (ACCME), requires that you disclose any
relevant financial relationships you or your spouse/partner have had within the past 24
months. For this purpose, "relevant financial relationships" are those from which you
have received or may receive financial benefit and which are related to this CME content.
By submitting this form, you agree that you have read the ASH Conflict-of-Interest
Policy and that you understand and support its intent.
Do you have any relevant financial relationship(s) to disclose? *
You must disclose the names of the organizations with which you have this relationship,
the nature of your relationship, and the clinical or research area involved.
Name of
Type of relationship:
a. Employment
b. Consultancy (Includes expert testimony)
c. Equity Ownership
d. Research Funding
e. Honoraria
f. Patents & Royalties
g. Speakers Bureau
h. Membership on an entity’s Board of Directors or
advisory committees
i. Other
Will your presentation and/or paper include information or discussion of off-label drug
use? *
Please describe the drug and its purpose below. This information will be disclosed to the
audience. *
Collect the following information from each abstract author.
Enter this information in the online system during abstract submission.
Please indicate your compliance with ASH policies and practices by checking each item
I have disclosed to the American Society of Hematology all relevant financial
relationships. If I am presenting in a venue sponsored by ASH, I will disclose this
information to the audience orally and provide this information as a disclosure slide
or in written form.
If I discuss off-label product use, I will disclose to participants/readers that the use is
If I am providing recommendations involving clinical medicine, they will be based
on evidence that is accepted within the profession of medicine as adequate
justification for their indication and contraindications in the care of patients. All
scientific research referred to in support of a patient-care recommendation will
conform to generally accepted standards of experimental design, data collection and
The presentation of the information with which I am involved will promote quality in
health care or advancements in science, and will not promote a specific proprietary
business interest or a commercial interest. Content for this activity and publication,
including any presentation of therapeutic options, will be well-balanced and
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g.
speakers’ bureau) for any commercial interest, the promotional aspects of that
presentation will not be included in any way with this activity or publication.
I represent that the information reported above is accurate. I understand that this
information will be disclosed publicly. I understand that failure to complete this
ASH Conflict-of-Interest Disclosure Form and comply with all aspects of the
ASH COI Policy will disqualify me from participating in the affected activity.