Faculty Invitation & Financial Relationships Form

32nd Annual Cardiovascular Interventions
November 16-19, 2021 • La Jolla, California

Your Name*
Enter your full name exactly as it should appear in the meeting materials.
First Last

Are you available to participate as a faculty member in the symposium?*
Faculty includes speakers, moderators, planners, peer reviewers, and course directors.

Yes, I agree to participate as a faculty member in the 32nd Annual Cardiovascular Interventions Symposium

No, I am unable to participate as a faculty member in the 32nd Annual Cardiovascular Interventions Symposium

Email*
Enter the email where you would like to receive future meeting correspondence.
Enter Email Confirm Email

Degrees/Credentials*
Enter the degrees/credentials you would like to appear in the meeting materials.

Salutation*

Are you an FACC or MACC?*

Hospital / Affiliation*
Enter your affiliation to be listed in the meeting materials

Academic and/or Hospital Title(s) you would like to appear in the meeting materials*
Enter n/a if you do not want to include any titles.

Hidden

Title(s) you would like to appear in the meeting materials
Enter n/a if you do not want to include any titles.

Mailing Address*
Street Address Address Line 2 City State ZIP Code

Assistant's Email
If you would like us to include your assistant on meeting correspondence, please enter their email here.

Phone Number*

Phone Type*

Fax Number

Permission*
Do you give permission to the "32nd Annual Cardiovascular Interventions" symposium to share your name and contact information (address only, no attendee emails will ever be shared) with sponsoring companies as part of a symposium attendee list?

Yes, I give my permission

No, I do not give my permission

As a prospective participant, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form below and click "Submit Form" when you reach the end.

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at [email protected]

Prospective role(s) in this activity - choose all that apply*
Speaker/Faculty
Moderator
Planner
Peer Reviewer
Course Director

Instructions for this form

1) Please disclose all financial relationships that you have had in the past 24 months with ineligible companies. An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. More information here.

2) For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s ). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution receives the research grant and manages the funds.

3) If the financial relationship existed during the last 24 months, but has now ended, please indicate in the field provided. This will help the education staff determine if any mitigation steps need to be taken.

Relationships Declaration*

In the past 24 months, I have had financial relationships with ineligible companies.

In the past 24 months, I have not had any financial relationships with any ineligible companies.

Financial Relationships*
To add additional relationships, click the plus button on the right-hand side.
Name of Ineligible Company Nature of Financial Relationship Has this relationship ended? Enter Yes or No

Consent*
I attest that the above information is correct as of this date of submission .

Date*
MM slash DD slash YYYY

Please click "submit form" below to submit your decline to participate.

Name of Ineligible Company	Nature of Financial Relationship	Has this relationship ended? Enter Yes or No