Hasbro Disclosure Form Name(Required) First Last Professional Title(Required) Title of Course(Required)Please select a courseFrontiers in Pediatric Surgery 2021Eating Disorders: Assessment and Treatment for Primary Care Providers (3/5/21)Effective Pediatric Pain Management and End of Life Care 2021 (3/6/2021)Pediatric Asthma & Allergy Update for Primary Care Providers 2021 (3/19/2021)Pediatric Cardiology Symposium for General Pediatrics: Focus on COVID-19 (4/27/21)Adolescent Medicine 2021 (5/17/21)Cerebral Palsy in 2021: Challenges and Opportunities for New Decade (6/6/21)Female Athlete Conference 2021 (6/10/21)New York Pediatric Advances: Cutting Edge Expertise Presented by Boston Children's Hospital and Boston Children's Health Physicians (5/5/21)Holy Family Summit 2021OtherTitle of your presentation(Required) Date of Education(Required) Use today’s date if the educational activity is an online enduring material.Location of Education (enter "online" if applicable)(Required) Role(s): Identify the prospective role(s) that you may have in the planning and the delivery of this education (choose all that apply)(Required) Course Director Activity Planner Faculty/Speaker Moderator Reviewer Other Role Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.Financial Relationships In the past 24 months, I have not had any financial relationships with any ineligible companies In the past 24 months, I have had financial relationships with the following company or companies: An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards. Name of Ineligible Company(Required) An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.Nature of Your Financial Relationship(Required) Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution.Has the Relationship Ended? Please check if the financial relationship existed during the last 24 months, but has now ended. This will help the education staff determine if any mitigation steps need to be taken. Add more financial relationships? No Yes Name of Ineligible Company Nature of Your Financial Relationship Has the Relationship Ended? Please check if the financial relationship existed during the last 24 months, but has now ended. This will help the education staff determine if any mitigation steps need to be taken. Name of Ineligible Company Nature of Your Financial Relationship Has the Relationship Ended? Please check if the financial relationship existed during the last 24 months, but has now ended. This will help the education staff determine if any mitigation steps need to be taken. Name of Ineligible Company Nature of Your Financial Relationship Has the Relationship Ended? Please check if the financial relationship existed during the last 24 months, but has now ended. This will help the education staff determine if any mitigation steps need to be taken. Name of Ineligible Company Nature of Your Financial Relationship Has the Relationship Ended? Please check if the financial relationship existed during the last 24 months, but has now ended. This will help the education staff determine if any mitigation steps need to be taken. Name of Ineligible Company Nature of Your Financial Relationship Has the Relationship Ended? Please check if the financial relationship existed during the last 24 months, but has now ended. This will help the education staff determine if any mitigation steps need to be taken. Optional file upload Drop files here or Select files Max. file size: 256 MB, Max. files: 10. Signature(Required) First Last Date(Required) MM slash DD slash YYYY If this is for an enduring material use today’s date.EmailThis field is for validation purposes and should be left unchanged.
