2010 Speaker and Co-Author Financial Disclosure Form

 
Society of Military Orthopaedic Surgeons
110 West Road, Suite 227, Towson, MD 21204
866-494-1778

Mandatory Financial Disclosure Statement

Below you will find a statement that will apply to you in connection with your participation in the Society of Military Orthopaedic Surgeon's 52nd Annual Meeting, December 13-17, 2010.

If you have a financial interest or other relationship with a commercial company, related directly or indirectly with SOMOS's 52nd Annual Meeting, provide the name of the commercial company. If not, indicate you have nothing to disclose. Your disclosure will be listed in the Final Program/Course Syllabus.

The Academy does not view the existence of these interests or committments as necessarily implying bias or decreasing the value of your participation in Academy activities.

 

I (or a member of my immediate family) have a financial interest or other relationship with a commercial company related directly or indirectly to the SOMOS 52nd Annual Meeting.


Please list below the name of the company or companies that apply to each statement.
1. Do you or a member of your immediate family receive royalties for any pharmaceutical, biomaterial or orthopaedic product or device? (LIST COMPANY NAME(S)


 
2. Within the past twelve months, have you or a member of your immediate family served on the speakers bureau or have you been paid an honorarium to present by any pharmaceutical, biomaterial or orthopaedic product or device company? (LIST COMPANY NAME(S)


3. Are you or a member of your immediate family a paid consultant or employee or unpaid consultant for any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier?
a. Employee (LIST COMPANY NAME(S)
b. Paid Consultant (LIST COMPANY NAME(S)
c. Unpaid Consultant (LIST COMPANY NAME(S)


 
4. Do you or a member of your immediate family receive any other financial/material support from any pharmaceutical, biomaterial or orthopaedic device and equipment company or supplier? (LIST COMPANY NAME(S)


 
5. Do you or a member of your immediate family own stock or stock options in any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier (excluding mutual funds)? (LIST COMPANY NAME(S)


 
6. Do you or a member of your immediate family receive research or institutional support from any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier? (LIST COMPANY NAME(S)


 
7. To the best of your knowledge, does your department/division/practice receive research or institutional support from any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier? (LIST COMPANY NAME(S)


 
8. Do you or a member of your immediate family receive any financial/material support from any medical and/or orthopaedic publishers? (LIST COMPANY NAME(S)


 
9. Do you or a member of your immediate family receive research or institutional support from any publisher? (LIST COMPANY NAME(S)


 
10. To the best of your knowledge, does your department/division/practice receive research or institutional support from any publisher? (LIST COMPANY NAME(S)


 
I have nothing to disclose.


 
Full Name *


 
I am *
a Speaker
a Co-Author


 
Speaker Author Name


 
Presentation Title *




(c) 2010 Society of Military Orthopaedic Surgeons
110 West Road, Suite 227
Towson, MD 21204
T: 866-494-1778
F: 410-494-0515
E-mail