The American Ophthalmological Society

FINANCIAL DISCLOSURE FORM

144th Annual Meeting
May 15 - 18, 2008
The Broadmoor
Colorado Springs, Colorado

Individuals need to disclose relationships with a commercial interest if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CME about the products or services of that commercial interest.

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. The ACCME has not set a minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. Use the following categories to indicate the type of financial relationships you are disclosing. If an individual is uncertain about what might constitute a potential financial conflict of interest, they should err on the side of full disclosure.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for your immediate family as defined above. If an individual is uncertain about what might constitute a potential financial conflict of interest, they should err on the side of full disclosure.

Category	Code	Description
Consultant / Advisor	C	Consultant fee, paid advisory boards or fees for attending a meeting (for the past 1 year)
Employee	E	Employed by a commercial entity
Lecture Fees	L	Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial entity (for the past 1 year)
Equity Owner	O	Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial ophthalmic products or commercial ophthalmic services
Patents / Royalty	P	Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant Support	S	Grant support for the past 1 year (all sources) and all sources used for this project if this form is an update for a specific talk or manuscript with no time limitation

I do not have any financial relationships to disclose.
I have the following financial relationships to disclose:

Company/Organization

Role ^*
(Check all that apply for each company listed.)

Consultant/Advisor Employee Lecture Fees Equity Owner Patents/Royalty Grant Support

Please be sure to enter your name as you want it to appear in the annual meeting program. (Fields marked as * are required.)

Abstract Title*

First Name and Middle Initial*

Last Name*

Degree(s)

Email*

Your Email again as your signature*

For co-authors: Please enter the Presenting Author's name.

Presenting Author's First Name and Middle Initial

Presenting Author's Last Name

I have read the Disclosure Requirements and to the best of my knowledge, the information provided in this form is true and correct and represents all items for Disclosure. I understand that failure to comply with the disclosure policy, when known and deliberate, may result in disqualification for two years from participation in similar AOS educational or related activities. I agree to promptly notify the AOS if any of this information changes.