2009 American Burn Association
Disclosure of Relevant Financial Relationships
Unlabeled or Investigational Use

Last Name:		First Name
Credentials:
Institution

ACCME defines "commercial interest" as "any proprietary entity producing health goods or related services, with the exemption of non-profit or government organizations and non-health care related companies."

ACCME defines "relevant financial relationships" as "financial relationships in any account occurring within the past (12) months that create a conflict of interest."

ACCME defines "conflict of interest" as "when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship."

1. Yes, I do have a relevant financial relationship with commercial interests
(listed below).

First, list the names of proprietary entities producing health care goods or services, with the exemption of non-profits or government organizations and non-health care related companies with which you or your spouse/partner have, or have had , a relevant financial relationship within the past (12) months.

Second, describe what you or your spouse/partner received (e.g. salary, honorarium, etc.) The ABA does NOT want to know how much you received.

Third, describe your role.

Name of Relevant Financial Relationship

Name of Commercial Interests	What was Received	For what Role

Examples of Terminology

What was received: Salary, royalties, intellectual property rights, consulting fee, honoraria, ownership interests (e.g. stocks, stock options, or other ownership interests, excluding diversified mutual funds), or other financial benefit.

Role(s): Employment, managing positions, independent contractor (including contracted research) consultation, speaking and teaching membership on advisory committees, review panels, board membership, "other activities" (please specify).

2. No, I do not have any relevant financial relationships with any commercial interests.

3. My presentation includes the discussion of any unlabeled use of commercial product or investigational use not yet approved for any purpose.

No

Yes, please specify:

Date Submitted: (mm/dd/yyyy)