Faculty Disclosure/FDA Form

The American Society for Laser Medicine and Surgery is accredited by the Accreditation Council for Continuing Medical Education (ACCME). This accreditation is very important for our organization and members. To achieve and maintain this accreditation, the ASLMS implemented a process for meeting the ACCME’s criteria for providing continuing medical education at the highest standard.

As part of this process, every person who is in a position to control the content of an ASLMS-sponsored education activity must disclose all relevant financial relationships with commercial interests. If such a financial relationship presents a conflict of interest or the appearance of a conflict of interest, the conflict will need to be resolved prior to continued involvement.

Please complete the disclosure form below and return it by the deadline indicated in your confirmation letter so we may be able to move to the next steps in planning the CME activity. If you decline to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of the CME activity.

ASLMS Disclosure of Interest Guidelines

• Written and verbal disclosure of financial interests or benefits you and your spouse/partner received within the last 12 months, and that no presentations are made with the appearance of a conflict of interest. If any conflict develops from the time you submit this disclosure form to the time of the CME activity, you must notify the ASLMS in writing and disclose the conflict.

• Written and verbal disclosure of any off-label uses of drugs or devices.

FDA approval is specific regarding approved uses and labeling of drugs and devices. The presenter must disclose whether or not the device or treatment is approved by the FDA or whether it is considered to be investigational. The presenter must also fully disclose any off-label use of devices, drugs, or other materials that constitute the subject of the presentation.

The ASLMS Central Office will prepare a conflict of interest statement to be included in printed program materials and a conflict of interest slide based on the information provided in this disclosure form. The slide will be inserted before each presentation on the Central Server and will include any proprietary interest in any drugs, instruments, or devices discussed in the presentation and/or any compensation received. Similarly, a slide will be shown to disclose the fact that the presentation content includes off-label uses of drugs or devices.

Faculty Disclosure/FDA Form

First name  Last name  Degree  Company name  Address  Address  City  State   Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming --- Canadian Provinces --- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan The Yukon --- United Kingdom States --- Zip  Country  United States Canada ----------------------------------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaidjan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guyana French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe (French) Guam (USA) Guatemala Guinea Guinea Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast (Cote D'Ivoire) Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique (French) Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia (French) New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Ireland Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Polynesia (French) Portugal Puerto Rico Qatar Reunion (French) Romania Russian Federation Rwanda Saint Helena Saint Kitts & Nevis Anguilla Saint Lucia Saint Pierre and Miquelon Saint Tome and Principe Saint Vincent & Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Tadjikistan Taiwan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Minor Islands Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (USA) Wallis And Futuna Islands Western Sahara Yemen Zaire Zambia Zimbabwe Phone  Fax  Email  Please check the boxes below that apply: [REQUIRED]    Annual Conference - I am (check one) Program Chair Section Chair Course/Workshop/Luncheon Director Course/Workshop Faculty For the: Course Laser Fundamentals in Health Care Course Laser and Light Source Hair Removal Course Laser Treatment of Patients of Color Course Skin Rejuvenation Course Nursing/Allied Health Course Laser Treatment of Vascular Lesions Course How Can We Use Diagnostic Information Course? Workshops Complications and Legal Issues Workshop Photodynamic Therapy Workshop Periocular Rejuvenation Workshop Technologies for Fat Related Disorders Workshop Emerging Technologies Workshop Luncheons My Approach to Fractional Resurfacing Improving Your Office Photography System: What You Really Need to Know Straight From the Source My Approach to Resurfacing Luncheon My Approach to Skin Tightening Technologies Non-Invasive Fat Removal: Where Do We Stand? A Comprehensive Recognition of Complications, Prevention and Treatment Encountered by Nursing/Allied       Health Professionals Molecular Effects of Laser Therapy and Other Cosmetic Treatments of Photodamaged Skin Expert Panels Evaluation and Treatment of Pediatric Lesions Expert Panel Through the Looking Glass: Different Views of Opportunities and Barriers for Photomedicine Skin Rejuvenation Expert Panel Disclosure of Information    I have read the disclosure guidelines above regarding my presentation(s) at the upcoming ASLMS Annual Conference. I understand that I must disclose all relevant information pertaining to the last 12 months: My spouse/partner and I do not have any relevant financial relationships with any commercial interests. OR The following financial relationships are relevant to my presentation(s). I agree to verbally disclose this information prior to my presentation(s) at the Annual Conference.    My spouse/partner and/or I received a financial grant from  My spouse/partner and/or I received equipment from  My spouse/partner and/or I received consulting fees from  My spouse/partner and/or I received a discount from  My spouse/partner and/or I had travel expenses paid by  My spouse/partner and/or I received a salary from  My spouse/partner and/or I hold ownership interests (e.g. stocks, stock options or other ownership interest, excluding diversified mutual funds or similar financial benefit) with  My spouse/partner and/or I received funding by a research grant from  My spouse/partner and/or I received royalties from  My spouse/partner and/or I received honoraria or gifts for educational services from  My spouse/partner and/or I hold an equity position with  My spouse/partner and/or I have intellectual property rights with  Other (if Other please explain and specify Company)  Please answer the following questions: [REQUIRED]    Has any federal, state, or local agency or court ever found that you made a false statement or omission or had been dishonest, unfair, or unethical? Yes No Have you ever had your medical or other professional license denied, suspended, revoked, or restricted? Yes No Are you now the subject of any proceeding or investigation that could result in a denied, suspended, revoked or restricted license? Yes No Are you or are you a relative of an ASLMS officer, director, or employee? Yes No Are you or are you a relative of an officer, agent, or employee of a vendor or supplier to ASLMS? Yes No Device approved by FDA Yes No NA/Non-clinical Investigational Device NOT approved by FDA Yes No NA/Non-clinical Disclose any off-label use of devices, drugs or other materials that constitute the subject of the presentation: Off label use NO Off label use NA/Non-clinical Electronic Signature: [REQUIRED]    I understand that recommendations in my presentation(s) 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. All scientific research referred to, reported on or used in my presentation(s) must conform to generally accepted standards of experimental design, data collection, and analysis. I further understand that my presentation(s) must not include recommendations, treatment, or manners of practicing medicine that are not within the definitions as noted above, are known to have risks or dangers that outweigh the benefits, or are known to be ineffective in the treatment of patients. I agree not to use materials or information prepared by commercial interests for promotional programs, and I will give a balanced presentation using the best available evidence to support my conclusions. I understand that if I refuse to disclose relevant financial relationships, I will be disqualified from being a part of the planning and implementation of this CME activity. I further understand that I may be unable to serve as faculty or to present my work at the scientific conference, courses, or other educational venues of the Annual Conference if I have an unresolved conflict of interest. E-mail:  Date:  Electronic Signature (Please type your name)