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

2a.) Funded Research Support

2b.) Royalties

2c.) Consultant Fees

2d.) Salary

2e.) Speakers Bureau

2f.) Honoraria

2g.) Stock Options

2h.) Equity Positions

2i.) Shareholder

2j.) Ownership

2k.) Other Financial

2l.) Material Support

2m.) Other

3.) 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 programs, which are objective and scientifically rigorous.
  • c.) I will not accept remuneration or any input regarding the content of the program from any commercial entity as defined by ACCME.

 Yes I agree to the terms

Full Name*

Email Address*

PGA70 – December 9-13, 2016