Virtual Meeting Participants Declaration Form

Virtual Meeting Participants
Declaration Form

"*" indicates required fields

Please specify the type of event in which you will be participating:

ISMRM Study Group Virtual Meeting

ISMRT Virtual Meeting

ISMRM Virtual Meeting

Joint ISMRT & Study Group Virtual Meeting

Enter the Title of the virtual meeting here:*

What role(s) are you invited for?*

Organizer

Moderator

Speaker

Identification/Badge Information

Name*

First Last

Institution*

Email*

Member ID number (if applicable)

Sections I and II below MUST be completed by all participants. Failure to complete them will disqualify you from participating in this event.

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.

I. PARTICIPANT AGREEMENT: OBSERVANCE OF ISMRM/ISMRT POLICIES

Please check each box below to acknowledge that you have read and understand each statement and will satisfy all of your obligations and responsibilities as a virtual meeting speaker.

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

Yes, I agree.

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 one piece of equipment exists by one manufacturer for this purpose, then that is acceptable.)

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.

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.

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

This does not preclude a faculty member from being reimbursed for expenses by their employer. This item limits only additional funding above reimbursements.

Yes, I agree.

The Content of accredited Continuing Education activities does not promote the proprietary interests of any ineligible companies.*

Yes, I agree.

Content of accredited Continuing Education 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. Trade names or company names should only be used if essential.*

Yes, I agree.

All published material and attributable work is appropriately cited.*

Yes, I agree.

Syllabus contributions, abstracts, and other required documents will be submitted as specified.*

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 accredited Continuing Education programs, and

2. presenting accredited Continuing Education 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 its policy on Identification, Mitigation, and Disclosure of Relevant Financial Relationships. In order to meet the policy requirements, please review and follow the instructions below.

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.

The information you provide addresses the requirements of the Accreditation Council for Continuing Medical Education (ACCME) to help ensure integrity and independence in accredited Continuing Education (CONTINUING EDUCATION) activities. Everyone in a position to control the content of an accredited CONTINUING EDUCATION 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 CONTINUING EDUCATION. ISMRM must mitigate relevant financial relationships and disclose these relevant financial relationships to participants prior to the beginning of the activity.

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.

For each type of relationship there is a drop-down list showing possible company names. You can also indicate “Other”, in which case the name of the company or other information must be entered in the space provided.

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.

The ISMRM does NOT want to know how much you received. Please do not provide the amount.

Disclosure*

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)*

Other - Describe nature of financial relationship*

Has one or more of the above relationships ended?*

Yes

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.

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.

III. PERMISSION TO RECORD AND/OR LIVE STREAM:

In continuation of the recent ISMRM/ISMRT initiative to increase the value of our meetings to registrants, all MR Learning Labs and other Virtual Meetings will be recorded and made available to meeting registrants via Adobe Connect, ismrm.org, and our ISMRT eLearning Center. In addition, these meetings will be live streamed to a virtual audience. The presentations will be made accessible to the MR community after the meeting and may be offered for a fee at the discretion of the ISMRM/ISMRT. The presentations may be used for continuing education courses for ISMRM/ISMRT

Permission to Record & Broadcast*

For virtual meetings, all sessions will be recorded and live streamed through our virtual platform or live meeting. These presentations will be password protected, accessible only to meeting registrants and ISMRM/ISMRT members. Highly received content may be repurposed as a stand-alone educational activity. No presentation will be rebroadcast on our website without the specific permission of the author.

Your permission is required to utilize your presentation(s) in these ways. Please indicate your understanding and agreement by selecting one of the following options.

I understand my presentation(s) will be live streamed and give permission to make the recording of my presentation(s) available to attendees and members. The presentation(s) may be used for Continuing Education courses for ISMRM/ISMRT.

I understand my presentation(s) will be live streamed but do NOT give permission to release the recording of my presentation(s). The presentation(s) may NOT be used for Continuing Education courses for ISMRM/ISMRT.