eaccme coi form demoule esicm forum madrid · european union of medical specialists (uems) european...
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EUROPEAN UNION OF MEDICAL SPEC IAL ISTS (UEMS)
EUROPEAN ACCRED I TAT ION COUNC I L ON CME ( EACCME® )
RUE DE L’INDUSTRIE 24, BE-‐ 1040 BRUSSELS T + 32 2 649 51 64 -‐ F + 32 2 640 37 30
https://eaccme.uems.eu -‐ [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 � BIC (SWIFT) BPOTBEB1 � VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Demoule…………………………………………. AFFILIATION: Alexandre……………………………………….
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial
or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of
the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-‐imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
X I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports: Philips, Maquet, Medtronic
Receipt of honoraria or consultation fees: Maquet, Medtronic, Baxter, Hamilton, Philips
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 25/11/2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : …………Takeshi Yoshida………………………………. AFFILIATION: ……St. Michael Hospital………………………………….
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
○,(
I have the following potential conflict(s) of interest to report
I have no potential conflict of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 2017/12/04
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Ramón Nogué Bou AFFILIATION: Universitat de Lleida, UDL · Department of Surgery
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
X I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Ramón Nogué Bou Date: 06/12/2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : ………Oriol Roca…………………………………. AFFILIATION: …Vall d’Hebron University Hospital…………………………………….
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
I have no potential conflict of interest to report
DISCLOSURE
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees: Hamilton Medical
Participation in a company sponsored speaker’s bureau: Fisher & Paykel
Air Liquide
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 30.11.17
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : MARIA PAZ FUSET CABANES AFFILIATION: HOSPITAL UNIVERSITARIO Y POLITÉCNICO LA FE. VALENCIA
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have the following potential conflict(s) of interest to report
I have no potential conflict of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: MARIA PAZ FUSET CABANES Date: 24/11/17
E U R O PE AN U N ION O F ME DI CA L S P E C IA L I S TS ( U EM S )
E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Maria Cruz martin Delgado MD Ph AFFILIATION: Hospital Universitario Torrejon Madrid, Spain
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live
Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial
or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also
must be made readily available, either in printed form, with the programme of the LEE, or on the website of the
organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-
imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
X I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES EUROPEAN UNION OF MEDICAL SPECIALISTS
Association internationale sans but lucratif – International non-profit organisation
AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE- 1050 BRUSSELS F +32 2 640 37 30 www.uems.net [email protected]
Spouse/partner:
Other support (please specify):
Signature: Maria Cruz Martin Date:30/11/2017
E U R O PE AN U N ION O F ME DI CA L SP E C IA L I S T S ( UEM S )
E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : …Marcelo Amato
AFFILIATION: INCOR –Heart Institute, University of São Paulo
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live
Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial
or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also
must be made readily available, either in printed form, with the programme of the LEE, or on the website of
the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-
imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports: Timpel Medical S.A.
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 17th-January-2018
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Luciano Gattinoni AFFILIATION: Universitätmedizin Göttingen
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau: Masimo ; Grifols ; Linet
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 26 November 2017
E U R OP E AN U NI ON OF M E D ICA L S P E CI AL I ST S (U E M S )
E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Lu Chen AFFILIATION: St. Michael’s Hospital, University of Toronto
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live
Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial
or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also
must be made readily available, either in printed form, with the programme of the LEE, or on the website of the
organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-
imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: November 30, 2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S )
E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes
IBAN BE28 0001 3283 3820 Ơ BIC (SWIFT) BPOTBEB1 Ơ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : LLUÍS BLANCH TORRA AFFILIATION: CORPORACIÓ SANITÀRIA PARC TAULÍ
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live
Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial
or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also
must be made readily available, either in printed form, with the programme of the LEE, or on the website of
the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-
imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
� I have no potential conflict of interest to report
� I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder: 10% Better Care, S.L. (Spin Off of Corporació
Sanitària Parc Taulí)
Spouse/partner:
Other support (please specify):
Signature: Date: 11/30/2017
EUROPEANUNIONOF MEDICAL SPEC IAL ISTS (UEMS) EUROPEAN ACCRED I TAT ION COUNC I L ON CME ( EACCME® )
RUEDEL’INDUSTRIE24,BE-1040BRUSSELS
T+3226495164-F+3226403730
https://[email protected]
UEMSaisbl–UnionEuropéennedesMédecinsSpécialistes
IBANBE28000132833820ǀBIC(SWIFT)BPOTBEB1ǀVATn°BE0469.067.848
ConflictofInterestDisclosureForm
NAME:…GuillermoMAlbaiceta……………………………………….
AFFILIATION:HospitalUniversitarioCentraldeAsturias.Oviedo,Spain.……………………………………….
Inaccordancewith criterion14ofdocumentUEMS2016/20 “EACCME®criteria for theAccreditationof Live
EducationalEvents(LEEs)”,alldeclarationsofpotentialoractualconflictsofinterest,whetherduetoafinancial
orotherrelationship,mustbeprovidedtotheEACCME®uponsubmissionoftheapplication.Declarationsalso
mustbemadereadilyavailable,either inprintedform,withtheprogrammeoftheLEE,oronthewebsiteof
the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-
imbursementofexpensesinrelationtotheLEEhasbeenprovided.
DISCLOSURE
XIhavenopotentialconflictofinteresttoreport
qIhavethefollowingpotentialconflict(s)ofinteresttoreport
Typeofaffiliation/financialinterest Nameofcommercialcompany
Receiptofgrants/researchsupports:
Receiptofhonorariaorconsultationfees:
Participationinacompanysponsoredspeaker’sbureau:
Stockshareholder:
Spouse/partner:
Othersupport(pleasespecify):
Signature: Date:24-Nov-2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME: GEMMA RIALP AFFILIATION: HOSPITAL SON LLATZER, PALMA DE MALLORCA. ILLES BALEARS
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Gemma Rialp Date: 12/02/2017
E U R OP E AN U NI ON OF M E D ICA L SPE C IAL I ST S (U EM S )
E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Fernando Suarez Sipmann AFFILIATION: Dept. Surgical Sciences, Hedenstierna Laboratory, Uppsala University. Uppsala, Sweden.
Department of Critical Care, Hospital Universitario de La Princesa, Madrid, Spain.
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live
Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial
or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also
must be made readily available, either in printed form, with the programme of the LEE, or on the website of
the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-
imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
X I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify): I perform consultan services
for Maquet Critical Care
U NION EUR OPÉENNE DES MÉDECINS SPÉCIAL ISTES EU R OPEAN U NION OF MEDICAL SPECIAL ISTS
Association internationale sans but lucratif – International non-profit organisation
AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE- 1050 BRUSSELS F +32 2 640 37 30 www.uems.net [email protected]
Signature: Fernando Suarez Sipmann Date: 26-11-2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Federico Gordo AFFILIATION: Henares University Hospital
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
X I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 30/11/2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : Georgopoulos Dimitrios…………………………………………. AFFILIATION: …University of Crete, Medical School…………………………………….
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
X I have no potential conflict of interest to report
I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Georgopoulos Dimitris Date: 30/11/2017
E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30
https://eaccme.uems.eu - [email protected]
UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848
Conflict of Interest Disclosure Form
NAME : ………Daniel Talmor…………………………………. AFFILIATION: …Beth Israel Medical Center…………………………………….
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
I have no potential conflict of interest to report
X I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees:- 1. Hamilton Medical 2. Faron
Participation in a company sponsored speaker’s bureau:
Stock shareholder: Intensix
Spouse/partner:
Other support (please specify):
Signature: Date: November 27 2017
E U R O P E A N U N IO N O F M E D IC A L S P E C IA L IS T S ( U E M S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )
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https://eaccme.uems.eu - [email protected]
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Conflict of Interest Disclosure Form
NAME : Antonio Pesenti AFFILIATION: Department of Pathophysiology and Transplantation, University of Milan
In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.
DISCLOSURE
q I have no potential conflict of interest to report
X I have the following potential conflict(s) of interest to report
Type of affiliation / financial interest Name of commercial company
Receipt of grants/research supports:
Receipt of honoraria or consultation fees: Baxter, Maquet, Xenios
Participation in a company sponsored speaker’s bureau:
Stock shareholder:
Spouse/partner:
Other support (please specify):
Signature: Date: 24/11/2017