2010 Financial Disclosure Form


Only one disclosure form is required per Speaker/Co-author.


Western Orthopaedic Association
110 West Rd, Suite 227, Towson, MD 21204
1-866-962-1388

Mandatory Financial Disclosure Statement

Below you will find a statement that will apply to you in connection with your participation in Western Orthopaedic Association's 74th Annual Meeting, August 5-7, 2010.

If you have a financial interest or other relationship with a commercial company related directly or indirectly with the WOA's 74th Annual Meeting, answer "Yes." Also include the name of the commercial company. Your disclosure will be listed in the Final Program/Course Syllabus.

The Academy does not view the existence of these interests or committments as necessarily implying bias or decreasing the value of your participation in Academy activities.

I (or a member of my immediate family) have a financial interest or other relationship with a commercial company related directly or indirectly to the WOA’s 74th Annual Meeting. *
Yes
I have nothing to disclose


Please list below the name of the company or companies that apply to each statement.

 
1. Do you or a member of your immediate family receive royalties for any pharmaceutical, biomaterial or orthopaedic product or device?


 
2. Within the past twelve months, have you or a member of your immediate family served on the speakers bureau or have you been paid an honorarium to present by any pharmaceutical, biomaterial or orthopaedic product or device company?


3. Are you or a member of your immediate family a paid consultant or employee or unpaid consultant for any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier?
a) Employee
b) Paid Consultant
c) Unpaid Consultant


 
4. Do you or a member of your immediate family receive any other financial/material support from any pharmaceutical, biomaterial or orthopaedic device and equipment company or supplier?


 
5. Do you or a member of your immediate family own stock or stock options in any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier (excluding mutual funds)?


 
6. Do you or a member of your immediate family receive research or institutional support from any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier?


 
7. To the best of your knowledge, does your department/division/practice receive research or institutional support from any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier?


 
8. Do you or a member of your immediate family receive any financial/material support from any medical and/or orthopaedic publishers?


 
9. Do you or a member of your immediate family receive research or institutional support from any publisher?


 
10. To the best of your knowledge, does your department/division/practice receive research or institutional support from any publisher?


 
Full Name *


 
I am *
Primary Author/Speaker
a Co-author


Primary Author/Speaker Name *


 
Presentation Title *
Date *




 

Western Orthopaedic Association
110 West Road, Suite 227

Towson, MD 21204

Phone: 866-962-1388
Fax: 410-494-0515
E-Mail: info@woa-assn.org