AMPC Courtesy Website

Please complete and submit Sections I and II of the form below. If this is not completed, you cannot speak at this CME activity or participate in its planning or implementation.

Please provide the requested identification information and check the participant agreement boxes to acknowledge that you have read this form and agree to all its provisions.
Identification Information
Name*
First Last
Institution*
Email*
Classification & Specialty
Professional Classification*
Please select all that apply
- Clinical Scientist
- Radiologist
- Basic Scientist
- Engineer
- Educator
- Industrial Management
- Radiologic Technologist
- Radiology Support Personnel
- Administrator
- Trainee/Student - Undergraduate
- Trainee - Graduate/Fellow
- Other Classification
Please list your other classification here:*
Clinician Specialty: Expertise/Training
Clinicians, please select all specialties that apply.
- Cardiology
- Internal Medicine
- Neurology
- Oncology
- Pathology
- Pediatrics
- Psychiatry/Psychology
- Radiology (incl. Nuclear Medicine)
- Surgery
- Other specialty
Please list your other specialty here:*
Scientist Specialty: Expertise/Training
Scientists, please select all specialties that apply.
- Physics (incl. Medical Physics, Biophysics)
- Mathematics (incl. Statistics)
- Chemistry
- Biology
- Physiology
- Anatomy
- Neuroscience/Psychology
- Other specialty
Please list your other specialty here:*
Engineer Specialty: Expertise/Training
Engineers, please select all specialties that apply.
- Biomedical Engineering
- Chemical Engineering
- Computer/Information Science
- Electrical Engineering
- Other specialty
Please list your other specialty here:*
Research Focus: Application
Please select all that apply.
- Nervous System
- Psychiatric/Psychological Disease
- Musculoskeletal
- Cardiovascular
- Breast
- Chest
- Abdomen
- Pelvis
- Cancer (general)
- Physiology/Metabolism
- Pediatrics (incl. Fetal)
- Animal Models
- Organ/Disease: Other
Organ/Disease: Other*
Research Focus: MR Methodology
Please select all that apply.
- Pulse Sequence Development
- Image Reconstruction
- Image Artifacts
- Image Analysis
- Engineering/Hardware
- MRI Safety
- Diffusion MRI
- Functional MRI
- MR Spectroscopy
- Molecular Imaging
- Vascular Imaging
- Quantitative MRI
- Interventional MRI
- Methodology: Other
Methodology: Other:*
I. Participant Agreement: Observance of ISMRM Policies - Mandatory

Please check each box below to acknowledge that you have read and understand each section, and will satisfy all these obligations and responsibilities of meeting organizers and speakers.
The content of CME activities does not promote the proprietary interests of any commercial interests.*
- Yes, I agree.
Content of CME activities will be restricted to pure science (dealing with physics, chemistry and biology as opposed to the business lines or products of any commercial interest) and should not include product or company names unless essential (and subject to guidelines below)*
- Yes, I agree.
Syllabus contributions, abstracts, and other required documents will be submitted as specified.*
- Yes, I agree.
All recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.*
- Yes, I agree.
All scientific research referred to, reported or used in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection and analysis.*
- Yes, I agree.
Unlabeled Uses of Products. When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity, the speaker is required to disclose that the product is not labeled for the use under discussion or that the product is still investigational.*
- Yes, I agree.
Generic and Trade Names: Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If trade names are used, those of several companies should be used rather than only that of a single manufacturer.*
- Yes, I agree.
To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.*
- Yes, I agree.
I will recuse myself from planning activity content in which I have a conflict of interest.*
- Yes, I agree.
I will not accept additional compensation* from any organization due to my involvement with the ISMRM.*
- Yes, I agree.
*Note: This does not preclude a faculty member from being reimbursed for expenses by their employer. This item limits only additional funding above reimbursements.
I attest that my opinions are my own and are not reflecting the opinions of my employer or other association.*
- Yes, I agree.
II. Declaration of Financial Interests or Relationships

The ISMRM is committed to:

1. ensuring balance, independence, objectivity and scientific rigor in all Continuing Medical Education programs, and
2. presenting CME activities that promote improvements or quality in healthcare and are independent of the control of commercial interests.

As part of this commitment, the ISMRM has implemented a process in which speakers and everyone else in a position to influence the content of an education activity discloses all financial relationships with any commercial interest, of any amount within the last 12 months (click on links for definitions). In addition, should it be determined that a conflict of interest exists as a result of a financial relationshipand the content to be presented, this will need to be resolved prior to the activity.

If you do not complete this form, whether or not you have relevant financial relationships, you will be disqualified from participating in the planning and implementation of this CME activity.

Affiliations and financial interests disclosed will be indicated in program and syllabus listings and during each talk. ISMRM does not imply that such financial interests or relationships are inherently improper or that such interests or relationships would prevent the speaker from making a presentation. The intent is that any and all conflicts are identified, managed and disclosed to participants so that learners may form their own judgments about the presentation in the light of full disclosure of the facts.

The declaration applies to any real or apparent financial interest or other relationship (i.e., grants, research support, consultant fees, honoraria, etc.) that the individual may have (or have had within the last 12 months) with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. This disclosure requirement extends to interests/financial relationships of spouses/partners. It does not apply to relationships with non-profit societies or governmental bodies.
Instructions

First, indicate in the Declaration Statement whether or not you (or your spouse/partner) have had any financial interest or relationships with commercial interests within the past 12 months.

Second, if you (or your spouse/partner) have financial interests, describe them under either:

A) Grant and Research Support,

B) Employment, or

C) Other types of relationships.

Give the names of relevant commercial entities. A drop-down list of some company names is provided. If the particular company does not appear on this list, please enter the name in the space provided. Relationships with non-commercial entities such as universities, hospitals, government agencies, foundations and non-profit societies are not to be included.

For “Other types”, provide a description of the relationship, what was received, and the name of the company. Drop-down lists are provided. If your particular entry does not appear on these lists, please describe it in the spaces provided. The ISMRM does NOT want to know how much you received. Please do not provide the amount.

Note: If you have more than one of a type of financial interest or relationship to disclose, please complete this form separately for each disclosure.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The Accreditation Council for Continuing Medical education (ACCME) does not consider providers of clinical service directly to patients to be commercial interests.
Declaration Statement

First, indicate in the Declaration Statement whether or not you (or your spouse/partner) have had any financial interest or relationships with commercial interests within the past 12 months.

Second, if you (or your spouse/partner) have financial interests, describe them under either:

A) Grant and Research Support,

B) Employment, or

C) Other types of relationships.

Give the names of relevant commercial entities. A drop-down list of some company names is provided. If the particular company does not appear on this list, please enter the name in the space provided. Relationships with non-commercial entities such as universities, hospitals, government agencies, foundations and non-profit societies are not to be included.

For “Other types”, provide a description of the relationship, what was received, and the name of the company. Drop-down lists are provided. If your particular entry does not appear on these lists, please describe it in the spaces provided. The ISMRM does NOT want to know how much you received. Please do not provide the amount.

Note: If you have more than one of a type of financial interest or relationship to disclose, please complete this form separately for each disclosure.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The Accreditation Council for Continuing Medical education (ACCME) does not consider providers of clinical service directly to patients to be commercial interests.
Do you have any financial relationships to report?*
Check 1 or 2 below, whichever applies to you; if you have checked 2, please describe financial interests/relationships in space provided.
- 1. I do not have any financial relationships to report.
- 2. I have a financial interest/arrangement with one or more entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. (If you have checked “2”, report the names of companies/organizations and types of relationships below.)
Are the commercial entities with which you have relationships relevant to the content you are planning, developing or presenting for this activity?*
- Yes, they are relevant
- No, they are not relevant
A. Grants & Research Support

Select from the drop-down menus.
1.
Other:*
2.
Other:*
B. Employment
Employment
Other:*
C. Other Types of Financial Interests
Relationship
Other:*
What Was Received
Other:*
Received From
Other:*
If you have another financial interest/relationship to disclose, please press "submit" and fill out the form again for each additional one.