SAGES Military Reviewer Form

Name*
First Last
Email*
Cell Phone*
Can you commit to reviewing abstracts and videos for SAGES 4th Annual Military Surgical Symposium?*
- Yes
- No
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), SAGES must insure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational activities. We are required to identify and resolve all potential conflicts of interest with any individual in a position to influence and/or control the content of CME activities. A potential conflict of interest is considered to exist if the individual and/or their spouse or partner has received financial benefit in any amount from a commercial interest involved in the activity within the past 12 months. A commercial interest is defined as any proprietary entity producing health care goods or services, with the exception of non-profit, government organizations or providers of clinical service directly to patients. All disclosure information will be reviewed to determine if a potential conflict of interest exists. Additional information may be requested to make this determination. Any changes in the disclosure information prior to the presentation should be forwarded to the SAGES office.
Please indicate if you have any relationships with industry to disclose. If you answer "Yes" to the below, we will need to collect the company information on the next step.*
- Yes, I or my spouse have at present or have had within the last 12 months a relevant financial relationship with a commercial interest.
- No, I or my spouse have NOT had within the last 12 months a relevant financial relationship with a commercial interest.

Third Relationship
Company*
What was Received?*
Please explain your choice of "other" above*
What was your Role with the Company*
Please explain your choice of "other" above*
Is this relationship relevant to your participation*
- Yes
- No
You answered YES to the question above, so now we need to resolve any potential conflict of interest.*
- The financial relationship does not relate to the content of my educational assignment/presentation.
- I will be using best available published evidence to support my presentation.
- I am changing my relationship with the commercial interest.
- All scientific data referenced or used as justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysis
- I suggest that my presentation be peer reviewed prior to the activity date.
- Other
- Unsure
Please fully explain your choice above.*

Confirmation*
- Confirmation
By checking this box I certify the preceding information is true and correct. I further agree that I will communicate any changes in my industry relationships to the SAGES as soon as possible.
Phone
This field is for validation purposes and should be left unchanged.

SAGES Military Reviewer Form

Military Reviewer Interest Form

Step 1 of 5

First Relationship

Second Relationship

Third Relationship

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