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Presenter Disclosure Form

Authors/Presenters

Financial Disclosure

Relevant financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, gift, speaking fee, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include “contracted research” where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. For all financial relationships, indicate the institution providing the funding for salary, royalties, grants, etc.

Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. May also include personal interest or cultural bias.

First Name Last Name

Email

Does this presenter have any relevant financial relationships to disclose: *required field

If yes, please provide an explanation of the disclosure:
 

Does this presenter have any relevant non-financial relationships to disclose: 

*required field

If yes, please provide an explanation of the disclosure:
 

Grants/Research Funding

List all applicable grants and research funding.

Presentations About Products or Services

Courses providing information about a product or service are to use the following guidelines:

  • Must provide information in a scholarly manner regarding theoretical aspects related to the product or service and/or the details of operation.
  • Must disclose prior to the course that there will be limited or no information provided about similar products or services
Will this presentation focus on information about a product or services: *required field

If the presentation will provide information about a product or service, please provide the name of the product/service:

Will the presentation contain information solely on the product/service noted above:

Will similar products/services be introduced in the presentation:

Disclosure to Attendees All presenters will be required to provide appropriate disclosures prior to the start of their presentation.


For questions on the submission, completion or content for the Call for Papers, contact the MSHA Office, office@msha.net or 855-727-2836.