Biographical & Conflict of Interest Form

Biographical & Conflict of Interest Form - 2014-2015 Department of OB/GYN

In an effort to streamline biographical and conflict interest forms for faculty and speakers for all of the Dept of OB/GYN continuing education events, an on-line form has been created. This form will apply to all of the Dept of OB/GYN, ANGELS and CDH educational events and the ANGELS Guidelines from July 2014 to June 2015.

Step 1 of 3

  • Disclosing a relevant financial relationship with an organization does not preclude involvement in the development, management, presentation, or evaluation of a CE activity. However, the Course Director must have resolved any conflict(s) of interest and the audience must be informed of all such relationships prior to the start of the activity. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners, faculty, moderators, and panelists must make full disclosure indicating whether they, and/or a spouse or domestic partner, have had any relevant financial relationships with commercial interests within the last 12 months. A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients (excepting non-profits, government organizations or providers of clinical service directly to patients). Individuals who refuse to disclose will be disqualified from participation in the CME activity. Failure to complete and return the form is the same as refusing to disclose.)

  • Please list your administrative assistant's name and contact information (if applicable)

  • Administrative Assistant's Name (if applicable):
  • (###)###-####
  • Max. file size: 74 MB.
    Please upload your most current CV/resume
  • Max. file size: 74 MB.
    Please upload an image of yourself for use in promotional materials.