+-----------------+-----------------+----+---+---------+---+---------+---+
| ![](m           | ## FACULTY      |    |   |         | ! |         |   |
| edia/image1.wmf | DISCLOSURE FORM |    |   |         | [ |         |   |
| ){width="1.7395 |                 |    |   |         | ] |         |   |
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+-----------------+-----------------+----+---+---------+---+---------+---+
|                 | ######          |    |   |         |   |         |   |
+-----------------+-----------------+----+---+---------+---+---------+---+
| ***Title of     | #####           |    |   |         |   |         |   |
| program:***     | # Prevention an |    |   |         |   |         |   |
|                 | d Management of |    |   |         |   |         |   |
|                 |  Disruptive Beh |    |   |         |   |         |   |
|                 | avior (cascade) |    |   |         |   |         |   |
+-----------------+-----------------+----+---+---------+---+---------+---+
| ***Location of  |                 |    |   |         |   |         |   |
| program:***     |                 |    |   |         |   |         |   |
+-----------------+-----------------+----+---+---------+---+---------+---+
| ***Program      | **Ongoing**     |    |   | ***     |   | ##      |   |
| date(s):***     |                 |    |   | Program |   | ######  |   |
|                 |                 |    |   | num     |   | ongoing |   |
|                 |                 |    |   | ber:*** |   |         |   |
+-----------------+-----------------+----+---+---------+---+---------+---+
| ***Contact      | **Wallace       |    |   | ####    |   | *       |   |
| person:***      | Jones**         |    |   | #### *P |   | *205-73 |   |
|                 |                 |    |   | hone:*  |   | 1-1812, |   |
|                 |                 |    |   |         |   | x204**  |   |
+-----------------+-----------------+----+---+---------+---+---------+---+
| ***E-mail       | #####           |    |   | #       |   | ####### |   |
| address:***     | ### <Wallace.Jo |    |   | ####### |   | # 205-7 |   |
|                 | nes@lrn.va.gov> |    |   |  *Fax:* |   | 31-1820 |   |
+-----------------+-----------------+----+---+---------+---+---------+---+
|                 |                 |    |   |         |   |         | # |
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+-----------------+-----------------+----+---+---------+---+---------+---+
| *               |                 |    | # |         |   |         |   |
| *[INSTRUCTIONS] |                 |    | # |         |   |         |   |
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| signed form to  |                 |    | # |         |   |         |   |
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| (above)         |                 |    | * |         |   |         |   |
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+-----------------+-----------------+----+---+---------+---+---------+---+

+----------+------+-----------------+----------------------------+---+
| ***Pre   |      |                 |                            |   |
| senter's |      |                 |                            |   |
| Name:*** |      |                 |                            |   |
+----------+------+-----------------+----------------------------+---+
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            | # |
|          |      |                 |                            |   |
+----------+------+-----------------+----------------------------+---+
| ***      | ***  | ***Presentation |                            |   |
| Date:*** | Time | Title:***       |                            |   |
|          | :*** |                 |                            |   |
+----------+------+-----------------+----------------------------+---+
| *        | *    | **     **       |                            |   |
| *     ** | *    |                 |                            |   |
|          |   ** |                 |                            |   |
+----------+------+-----------------+----------------------------+---+

Employee Education System must insure balance, independence,
objectivity, and scientific rigor in all EES sponsored educational
activities. All faculty participating in an EES-sponsored activity are
expected to disclose to the activity audience any significant financial
interest or other relationship with: (1) the manufacturer(s) of any
commercial product(s) and/or provider(s) of commercial services
discussed in this educational presentation and (2) any commercial
supporters of the activity. **Significant financial interest or other
relationship can include such things as grants or research support,
employee, consultant, major stockholder, member of speakers' bureau,
etc. The intent of this disclosure is not to prevent a speaker with a
significant financial or other relationship from making a presentation,
but rather to provide listeners with information on which they can make
their own judgments. It remains for the audience to determine whether
the speaker's interests or relationships may influence the presentation
with regard to exposition or conclusion.**

When a use not approved by the FDA of a commercial product, or an
investigational product not yet FDA approved for any purpose is
discussed during an educational activity, EES shall require the speaker
to disclose that the product is not labeled for the use under discussion
or that the product is still investigational.

+---+----------------------------------------------------------+---+----+
| * |                                                          | # | #  |
| * |                                                          |   | ** |
| P |                                                          | * | No |
| L |                                                          | * | ** |
| E |                                                          | Y |    |
| A |                                                          | e |    |
| S |                                                          | s |    |
| E |                                                          | * |    |
| C |                                                          | * |    |
| O |                                                          |   |    |
| M |                                                          |   |    |
| P |                                                          |   |    |
| L |                                                          |   |    |
| E |                                                          |   |    |
| T |                                                          |   |    |
| E |                                                          |   |    |
| * |                                                          |   |    |
| * |                                                          |   |    |
+---+----------------------------------------------------------+---+----+
| 1 | Will this presentation include discussion of any         |   |    |
| A | commercial products or services?                         |   |    |
+---+----------------------------------------------------------+---+----+
| # | # [If Y                                                  |   |    |
|   | ES TO 1A]{.underline}: Will you discuss any uses not app |   |    |
| 1 | roved by the FDA for pharmaceuticals or medical devices? |   |    |
| B |                                                          |   |    |
|   |                                                          |   |    |
| # |                                                          |   |    |
|   |                                                          |   |    |
+---+----------------------------------------------------------+---+----+
| 1 | [If YES TO 1B:]{.underline} please list any uses not     |   |    |
| C | approved:                                                |   |    |
+---+----------------------------------------------------------+---+----+
| 2 | Do you have a significant financial interest or other    |   |    |
| A | relationship with the manufacture(s) of any of the       |   |    |
|   | product(s) or provider(s) of any of the services you     |   |    |
|   | intend to discuss in this presentation?                  |   |    |
+---+----------------------------------------------------------+---+----+
| # | If YES, please list the manufacturer(s) or provider(s)   |   |    |
|   | and describe the nature of the relationship(s):          |   |    |
| 2 |                                                          |   |    |
| B |                                                          |   |    |
+---+----------------------------------------------------------+---+----+
| # | # This a                                                 |   |    |
|   | ctivity is supported by an educational grant from:       |   |    |
| 2 |                                                          |   |    |
| C |                                                          |   |    |
+---+----------------------------------------------------------+---+----+
| 3 | Do you have a significant relationship(s) with the       |   |    |
| A | commercial supporter(s) of this activity?                |   |    |
+---+----------------------------------------------------------+---+----+
| # | # If YES, please list the relevant commerci              |   |    |
|   | al supporter(s) and describe the nature of the relations |   |    |
| 3 | hip(s). (Please note if answer is the same as #4.)       |   |    |
| B |                                                          |   |    |
+---+----------------------------------------------------------+---+----+
| 4 | Will this presentation include reference to drugs or     |   |    |
| A | medical devices?                                         |   |    |
+---+----------------------------------------------------------+---+----+
| 4 | Will you discuss any uses not approved by the FDA for    |   |    |
| B | pharmaceuticals or medical devices?                      |   |    |
+---+----------------------------------------------------------+---+----+
| 4 | # If YES to 1B, please list:                             |   |    |
| C |                                                          |   |    |
+---+----------------------------------------------------------+---+----+

Please note that if any questions are posed to you during your
presentation that require you to address

any such unapproved uses, that you clarify that to the audience in your
response.

  ------------------------------------ ----------------- ----------------
                                                         **     **

  ------------------------------------ ----------------- ----------------

***Signature**s required insert Date*