Conflict of Interest Disclosure - Step 2

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Conflict of interest disclosure

Thank you for your interest in joining a MNCM workgroup for various measurement reviews. To apply, please carefully read our conflict of interest policy then complete the information below.




Disclosures

Financial Relationships*: (?)
Examples: Speaking/Consulting, Honoraria, Outside Payment for Participation in this Work Group, Paid Expert Testimony, Patents (pending), royalties or other compensation for intellectual property, Payment for development of educational presentations including service on speakers’ bureaus, Stock, stock options or other corporate ownership (including medical devices, services or health information technology), Organization that is involved with measure development, accreditation, certification or recognition, Other


Programmatic Support*: (?)
Examples: Grants/pending grants, Travel/accommodation expenses covered or reimbursed, Industry or grant funding of salary or position, Other


Non-Financial Associations*: (?)
Examples: Board Memberships, Advisory councils, Consulting, Specialty Societies




Financial Relationships involving spouse, partner or children (under 18 y/o) *

Do your children, spouse or partner have financial relationships with entities that have an interest in the content of this work?


Non-MNCM Work group disclosure *

In the last five years, have you served on any non-MNCM measure development work groups?



For members of Speaker’s Bureaus, only.

Please attach the titles of the presentations you gave in the last 12 months and have planned for the next 12 months.

If you have published any scientific articles, commentaries or opinions pieces relevant to this topic area, please attach the citations.

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Confirmation of electronic signature
By selecting this checkbox, you are signing this Disclosure electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Disclosure, and that no other authority or third party verification is necessary to validate your e-signature.