Presenter/Speaker Personal Disclosure (Sample)

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Presenter/Speaker Personal Disclosure (Sample)
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PresenterSpeaker Personal Disclosure (Sample) Presenters Name: Enter Name Here I have no current or past relationships with commercial entities OR I have the following relationships with commercial interests: Advisory BoardSpeakers

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Presenter/Speaker Personal Disclosure (Sample) Presenter’s Name: [Enter Name Here]

I have no current or past relationships with commercial entities

OR

I have the following relationships with commercial interests:
Advisory Board/Speakers Bureau – [entity names]
Funding (Grants/Honoraria) : [entity names]
Research/Clinical Trials: [entity names]
Speaker/Consulting Fees: [entity names]
Other:
Current/past Employee of [entity names]
Investments: Investments in sponsor organization or entity with product in program
Patent in product

Speaking Fees for current program:
I have received a speaker’s fee from [name of organization] for this learning activity
OR
I have received no speaker’s fee for this learning activity<br>