Workshop Agreement & Disclosure Form

ISMRM Workshop
Agreement & Disclosure Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Are you able to participate at this workshop?*

Yes, I accept

No, I decline

Full Name*

Including credentials

Full Name*

Including credentials

Your Email*

Confirmation will be sent to this address

Degree(s)*

Institution*

Institution Location*

City State / Province / Region Country

Please specify the event in which you are participating:*

Please specify the event in which you were invited to:*

What role(s) are you invited for?*

Organizer

Moderator

Speaker

Abstract Presenter

Have you submitted a disclosure form for this workshop?*

Yes, I have submitted a disclosure form for this workshop and have no changes to financial relationship(s) with ineligible companies

No, I have not submitted a disclosure form for this workshop

INSTRUCTIONS:

First, check the "Participant Agreement" and “Validation Statements” boxes below to acknowledge that you have read this form and agree to all its provisions.

Second, please disclose all financial relationships (any amount) that you have had in the past 24 months with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

For each type of relationship you will need to enter your company names.

If the type of relationship you disclose does not fall under one of the categories shown, please enter it in the "Other" section at the bottom of the form.

PARTICIPANT AGREEMENT:

Please check each box below to acknowledge that you have read this form and agree to all its provisions including observance of the following ISMRM policies:

I agree to submit all requested materials as outlined by ISMRM prior to the provided deadline.*

Yes, I agree.

Industry logos cannot be displayed during the presentation. Please ensure that your slides do not use a corporate logo.*

If an image of equipment must be used, and the display of a logo is unavoidable, please include multiple pieces of equipment from different manufacturers that are able to perform the same task. (If only once piece of equipment exists by one manufacturer for this purpose, then that is acceptable.)

Yes, I agree.

The first slide in your presentation should include your name and disclosure information (or lack thereof) but should not include company logos (see above).*

Yes, I agree.

I will not accept additional compensation from any organization due to my involvement with 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.

All published material and attributable work is appropriately cited.*

Yes, I agree.

Validation Statements

ISMRM supports the validation of clinical content for all accredited CE activities. Please review the following statements and indicate your intent to comply with each expectation.

All recommendations for patient care in the activity, must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.*

Yes, I agree.

All scientific research referred to, reported, or used in the activity, in support or justification of patient care recommendation, must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.*

Yes, I agree.

The content will NOT advocate for unscientific approaches to diagnosis or therapy, nor promote recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.*

Yes, I agree.

Disclosure

Purpose: The information you provide addresses requirements of the Accreditation Council for Continuing Medical Education (ACCME) to help ensure integrity and independence in accredited Continuing Education (CE) activities. Everyone in a position to control the content of an accredited CE activity must disclose all financial relationships with ineligible companies, within the past 24 months (whether the relationship has now ended or is currently active) to the ISMRM. The Standards for Integrity and Independence in Accredited CE require that ISMRM disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited CE. ISMRM must mitigate relevant financial relationships and disclose these relevant financial relationships to participants prior to the beginning of the activity.

Definition: An ineligible company is any entity whose primary business is producing marketing, selling, re-selling, or distributing healthcare products used by or on patients. Please Note: According to the ACCME, this definition does not apply to a start-up company that “has not initiated a governmental regulatory approval process,” meaning it has not crossed the line from being eligible to ineligible.

Instructions: Please disclose all financial relationships (any amount) that you have had in the past 24 months with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Regarding my role in accredited CE activities (check one)*

No, I have no financial relationship(s) with ineligible companies.

Yes, I have financial relationship(s) with ineligible companies.

Nature of Financial Relationship*
Check all that apply
Employee
Owner/Co-Owner
Founder/Co-Founder
Consulting Fee (e.g., Advisory Board)
Contracted Research (Must provide information, even if received by the institution)
Honoraria
Speakers’ Bureau
Stock Shareholder (Individual stocks; diversified mutual funds do not need to be disclosed)
Stock Options
Royalty
Other

Employee - Name of Company(s)*

Owner/Co-Owner - Name of Company(s)*

Founder/Co-Founder - Name of Company(s)*

Consulting Fee - Name of Company(s)*

Contracted Research - Name of Company(s)*

Honoraria - Name of Company(s)*

Speakers’ Bureau - Name of Company(s)*

Stock Shareholder - Name of Company(s)*

Stock Options - Name of Company(s)*

Royalty - Name of Company(s)*

Other - Name of Company(s)*
Describe nature of financial relationship

Has one or more of the above relationships ended?*

Yes

No

If the financial relationship existed during the last 24 months, but has now ended, please indicate this below*

Mitigating Relevant Financial Relationships: Should ISMRM determine that a disclosed financial relationship(s) is relevant, ISMRM will begin a series of steps to mitigate the relevant financial relationship(s) based on the individual’s role in the activity and identify what, if any, action is necessary. The mitigation mechanism will identify potential bias and ensure content is aligned with interests of the learner. Only when the relevant financial relationship(s) has been mitigated may the individual participate in the activity.

Permission to Record

Please check one:*

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.

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

Signature & Attestation*
By typing my full name, I attest this annual disclosure is correct and complete and will provide any updates/changes to the status of this information, promptly.
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