2023 JNESO Convention Financial Disclosure

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Name*

First Last Credentials

Email Address*

Phone*

In the past 24 months, have you had any financial relationships with any ineligible companies?*

Ineligible companies: An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit this webpage for more information.
There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Types of financial relationships you may need to report: Examples include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest). Individual stocks and stock options must be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies must be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

Yes

Please list all relationships below*

Please enter the name(s) of the ineligible company(ies) with which you have financial relationships to disclose, and the nature of those relationships. Example: “ABC Pharmaceutical Company, consultant and speaker”

If any of the financial relationships existed during the last 24 months, but have now ended, please answer “yes” in the far right column. This will help us determine if any mitigation steps need to be taken.

Name of ineligible company(ies)

Nature of relationship(s)

Has this relationship ended? (Y/N)

Electronic Signature*

First Last

2023 JNESO Convention Financial Disclosure

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