MidSouth Pharmacy Conference Information

MidSouth Pharmacy Residents Conference COI 2017

Asterisk (*) indicates a required field.

Contact Information

First Name*

Middle Initial

Last Name*

Email Address*

Phone Number*

Address 1*

Address 2

City*

State/Province/Region*

Zip/Postal Code*

Sponsorship and Conflict of Interest Declaration for all Speakers

Having an interest in, or affiliation with, a commercial interest does not prevent a speaker from making a presentation, but the relationship must be made known to the audience in accordance with the standards of the Accreditation Council for Continuing Pharmacy Education. In order to fulfill this obligation, please assist us by completing the following information regarding relationships held within the past 12 months (this includes spouse/life partner affiliations as well).

I have relevant conflicts of interest to report*

Yes No

Initials*

Describe any relevant financial relationship

Consultant fees (includes advisory boards)

Intellectual property rights/patient holder

Ownership interest (stock/stock options)

Salary, royalty, honoraria

Speaker's bureaus

Supported/contracted research

Other

If any unapproved or off-label uses of products will be discussed, disclosure must be made to the participants regarding the unapproved or off-label use.

I will be discussing the use of unapproved or off-label products:*

Yes No

Initials*

I agree to share this information with St. Jude*
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