AMERICAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS

Financial Relationships Disclosure Form
For Faculty, Authors, Committee/Board Members, and Staff
Organizations accredited by the American Dental Association Continuing Education Recognition Program (ADA CERP) andAccreditation Council for Continuing Medical Education (ACCME) are required to identify and resolve all potential conflicts ofinterest with any individual in a position to influence and/or control the content of CDE/CME activities. A conflict of interest will beconsidered to exist if: (1) the individual has a ‘relevant financial relationship;’ that is, he/she has received financial benefits ofany amount, within the past 12 months, from a ‘commercial interest’ (an entity producing, marketing, re-selling, or distributing
health care goods or services consumed by, or used on, patients), and (2) the individual is in a position to affect the content ofCDE/CME regarding the products or services of the commercial interest.
All individuals in a position to influence and/or control the content of AAOMS CDE/CME activities are required to disclose
to the AAOMS, and subsequently to learners: (1) any relevant financial relationship(s) they have with a commercialinterest, or (2) if they do not have a relevant financial relationship with a commercial interest.
Failure to provide disclosure information in a timely manner prior to the individual’s involvement will result in thedisqualification of the potential Faculty, Author, Committee/Board Member, or Staff, from participating in the CDE/CME
activity.
Title of CME activity: ________________________________________________________________________________
Name: _____________________________________________________ Date: ________________________________
Please check one to indicate your role:___ Faculty___ Author___ Committee Member (specify: ______________________)___ Staff___ Other (specify: ____________)___ Board of Trustees

Phone Number: _____________________________________ E-mail: _______________________________________DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM____ Neither I, nor any member of my immediate family, has a financial relationship or interest (currently or within the past 12months) with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,patients.
OR____ I have or ___an immediate family member has a financial relationship or interest (currently or within the past 12 months) withany entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The
financial relationships are identified as follows (if needed, attach an additional list):
RELEVANT FINANCIAL RELATIONSHIP(S) RELATED TO YOUR CONTENT(check all that apply)
Commercial Interest(s)(any entity producing, marketing, re-selling,or distributing health care goods orservices consumed by, or used on,patients.)

Research Grant(including funding
to an institution forcontractedresearch)

Speakers’BureauStock/Bonds(excludingMutualFunds)

ConsultantOther(Identify)

I affirm that the foregoing information is complete and truthful, and I agree to notify AAOMS immediately if there are anychanges or additions to my relevant financial relationships. During my participation in this activity, I will wholly support
AAOMS’ commitment to conducting CDE/CME activities with the highest integrity, scientific objectivity, and without bias. Iagree that I will not accept any honoraria, additional payments or reimbursements beyond what has been agreed upon to
be paid directly by AAOMS in relation to this educational activity.
Signature: _______________________________________________________

Date: ____________________