The New York State Society of Anesthesiologists, Inc.


1.) *Do you or your spouse/partner have, within the last 12 months, a relevant financial interest or other relationship with a commercial entity (A commercial interest is any entity producing, marketing, re-selling, or distributing health goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical services directly to patients to be commercial interests.)

2.) *Do you intend to discuss an unlabeled/unapproved/experimental/investigational drug or device (not FDA approved)? If YES, you agree to acknowledge this to the learners.

3.) Is the content of your presentation based on research that was supported by an industry grant? (Do not consider grants from government or non-profit organizations or non-health related companies)

4.) If you answered yes to questions 1 and/or 3 please indicate the type of support and who it is from below

4a.) Funded Research Support

4b.) Royalties

4c.) Consultant Fees

4d.) Salary

4e.) Speakers Bureau

4f.) Honoraria

4g.) Stock Options

4h.) Equity Positions

4i.) Shareholder

4j.) Ownership

4k.) Other Financial

4l.) Material Support

4m.) Other

5.) I agree to the following (If you do not agree, you cannot participate in this program):

  • a.) If any of the above information changes, I will notify NYSSA immediately.
  • b.) I will prepare fair-and-balanced presentations, which are objective and scientifically rigorous.
  • c.) I will not accept remuneration or any input regarding the content of the presentation(s) from any commercial entity as defined by ACCME.
  • d.) Recommendations will be based on evidence that is accepted within the profession of medicine.
  • e.) I will not advise or recommend a diagnosis or treatment in which the risks outweigh the benefits.
  • f.) I will use scientific or generic names in referring to products in my lecture or enduring materials. Should it be necessary to use a trade name, then I will use trade names of all similar products or those within a class. For any product that I discuss, I will discuss both the benefits and limitations of that product and those of the products in that class of drugs. I will not stress one product over another without scientific evidence for recommendations.
  • g.) I agree to obtain the necessary copyright permission(s) if any portion of my presentation is not my original work and for which I do not hold the copyright.
  • h.) I attest that my materials will be HIPAA compliant (i.e., will only use de-identified patient information).
  • i.) My slides or enduring materials will not contain any advertising, trade names, or product group messages.
  • j.) I will submit my syllabus materials by the requested deadline date according to guidelines outlined in the speaker invitation letter.
  • k.) I will ensure that a commercial interest representative will NOT be involved in my presentation or the discussion afterwards.

 Yes I agree to these terms

Full Name*

E-mail Address*

PGA70 – December 9-13, 2016