Faculty Disclosure: Annual North American Conference for RRM – Institute of Restorative Reproductive Medicine of America

Name *

First

Last

Email *

Title of Presentation *

Degrees or professional affiliations or designations *

Phone Number *

Do you or does any member of your immediate family have a financial relationship or interest with any proprietary entity producing health care goods or services? *

Yes
No

Please check the relationship(s) below:

Please describe other relationships in the space provided below:

Please indicate the names of all organizations in which you have a financial relationship or interest and the specific clinical areas that correspond to the relationship (if applicable)

Have you received an honorarium, consulting fee, or any other type of compensation from a proprietary entity producing health goods or services that relate to the topic of your presentation? *

You indicated yes. Please provide the pertinent details below.

Will your presentation include slides or printed materials provided by a proprietary entity? *

You indicated yes. Please provide the pertinent details below.

Will the content of your presentation include discussion of unapproved or investigational uses of pharmacological, biological, and medical products or devices. This includes the off-label use of pharmacological drugs? *

Please list which unapproved or investigational uses of pharmacological, biological, and/or medical products or devices will be discussed.

Please list 2-5 learning outcomes that attendees will gain from your presentation. *

For an explanaton and examples of devloping learning outcomes for CME please view this link: https://iirrm.org/learning-outcomes/.

I give permission for the recording of my presentation to offer additional access to those that were unable to attend live, and to those that attended but may want to review the materials. Presentations are posted behind a paywall and are only used for educational purposes. The speaker retains all copyright in relation to the presentation, text and graphics. *

Yes
No
Yes, with the following conditions:

I acknowledge that I will retain all copyright in relation to the text and graphics contained within my presentation. I consent to the presentation being distributed by IRRMA in electronic files, including slides or handouts and posting of the recording to the IRRMA website. This information will be securely protected behind a paywall and used for educational purposes only to those that attended live, or purchase access to the conference recordings. *

Yes
No
Yes, with the following conditions:

I have answered these questions to the best of my knowledge. If I have a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest may require IRRMA to identify a replacement. *

I understand that in checking this box I acknowledge and agree to the above terms of acceptance.

Signature *

Clear Signature

Submitted on : *

Presenter Full Disclosure Form All CME Activities

Presenter Full Disclosure Form
All CME Activities