Conflict Of Interest And Upload Presentation — NEUROSURGICAL SOCIETY OF THE VIRGINIAS

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Individual's prospective role(s) Identify the prospective role(s) that this person may have in the planning and delivery of this education (choose all that apply)

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To be Completed by Physician Planner, Planner, Faculty, or Others Who May Control Educational Content. 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.

Enter the Name of Ineligible Company 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.

Enter the Nature of Financial Relationship 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST be disclosed by the principal or named investigator even if that individual's institution receives the research grant and manages the funds.

Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken.

Please click one if applicable.

In the past 24 months, I have not had ANY financial relationships with any ineligible companies.

I grant permission to reproduce and distribute my materials (slides & audio). If not my own material, I have secured the author's permission.

I do not grant permission to reproduce and distribute my materials (slides & audio)

I understand it is my responsibility to update my ineligible financial relationships as they occur throughout the year, between signed disclosure form

I attest that the above information is correct as of this date of submission.

* By typing in my name and the current date, I acknowledge that the information provided is accurate and true.

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