Declarations Form

Faculty & Organizers
Declarations Form

"*" indicates required fields

Please specify the event in which you are participating:*

If you are participating in an event not listed above, please specify:

What role(s) are you invited for?*

Organizer

Moderator

Speaker

If you do not complete and submit Sections I and II of the form below, 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/Badge Information

Name*

First Last

Institution*

Email*

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 ACCME-defined ineligible company.*

Yes, I agree.

Content of CME activities will be restricted to pure science (dealing with physics, chemistry and biology), industry issues and operation of devices, as opposed to the business lines or products of any ineligible company, and should not include any advertising, corporate logos, trade names or a product group message of an ACCME-defined Ineligible Company. If reference to product or company names is essential, it is subject to the 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 must be used for clarification only, those of several companies should be used rather than only that of a single manufacturer.*

Yes, I agree.

Should there be a perceived conflict of interest regarding my presentation or involvement as an organizer, I agree to work with ISMRM to resolve the conflict as soon as possible prior to the presentation, activity or posting of educational materials.*

Yes, I agree.

II. Declaration of Financial Interests or Relationships

The ISMRM is committed to...

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

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 ineligible company, of any amount within the last 24 months (click on links for definitions). In addition, should it be determined that a conflict of interest exists as a result of a financial relationship and 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 ineligible companies within the past 24 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 ineligible companies. 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 eligible companies 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.

An ineligible company 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 ineligible companies.

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Declaration Statement

Have you (or your spouse/partner) had a financial relationship with an ineligible company in the last 24 months?*

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.

Are the ineligible companies 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

Has one or more of the above relationships ended?*

If one or more of the financial relationships above existed during the past 24 months, but has now ended, select Yes below. This will help the education staff determine if any mitigation steps need to be taken.

Yes

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A. Grants & Research Support

Select from drop-down menus.

Other:

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B. Employment

Select from drop-down menus.

Employment

Other:

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C. Other Types of Financial Interests

Select from drop-down menus.

Relationship

Other:

What Was Received

Other:

Received From

Other:

If you have another financial interest/relationship to disclose, please click "submit" and fill out the form again for each additional disclosure.

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III. Permission to Record

Please check one:*

A. I give permission for my presentation to be recorded and made available to workshop registrants on the ISMRM website. I understand that the presentations will be password protected and accessible only to workshop registrants for one year after the workshop, and to ISMRM members for the second year after the workshop. In addition, I give permission for my presentation to be made available to the MRI radiographer and technologist community via the ISMRT eLearning Center for future viewing. The presentations may be used for continuing education courses for ISMRT.

B. I do not give permission for my presentation to be recorded and made available as described above.

Annual Meeting Permission to Record*

For the 2022 meeting, all sessions will be recorded, live streamed though our virtual platform or live meeting, and made available to meeting registrants on the ISMRM/ISMRT web site 30 days after the meeting. These presentations will be password protected, accessible only to meeting registrants and, after the end of the year, to ISMRM/ISMRT members. Highly received content may be repurposed as a stand-alone educational activity. No presentation will be broadcast on our website without the specific permission of the author.

We need your permission in order to include your presentation in this program. It is REQUIRED that you select one of the options below in order to submit your contribution.

With permission to record I also agree that a recording of my presentation can be made public through the MR Academy.

I understand my presentation will be live streamed and give permission to record my presentation. The presentations may be used for continuing education courses for ISMRM/ISMRT.

I understand my presentation will be live streamed but do NOT give permission to release the recording of my presentation. The presentations may NOT be used for continuing education courses for ISMRM/ISMRT.