1 of 6 10/5/2015 12:58 PM Introduction IASLC Conflict of Interest (COI) Disclosure Form for Individuals - 2015-2017 This form and policy applies to all persons who: are members, employees, or staff of IASLC, or seek to make presentations at any IASLC meeting and/or submit to any IASLC sponsored publication, including JTO; or participate on the IASLC Board of Directors, Committees, JTO Editorial Staff, or in any volunteer activity in an official capacity. Covered other persons are those related to the declaring individual if they have a relationship as spouse, dependent child, or adult child employed by the sponsor, or any other relationship involving the sharing of income or assets. Click here to View/Download the complete IASLC COI Disclosure Policy. Please see Explanatory tes/frequently Asked Questions We encourage all indidivuals to use the electronic, interactive form. If you need the electronic form link re-sent to you, please contact membership@iaslc.org. After you complete the form below, please send to membership@iaslc.org. If you have any problems with the form below, please contact IASLC at membership@iaslc.org or dial +720.325.2956. Please include the following information: Your First/Given Name Your Last/Family Name Institution Location (City, State, Country) Email Confirm Email Please select Role(s) with IASLC. Select all that apply: Board Member Committee Member or Chair Invited Speaker Staff Member JTO Editorial Staff Other Item 1: Employment or Leadership Position - Check if you or an immediate family member is or in the past two years has been employed by, serves as an officer of, or serves as a director of any entity having an investment, licensing, or other commercial interest in any drugs, products, or services that are the subject of the matter under consideration. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 1.1: If yes, please disclose for each position (add additional entities if necessary): Entity 1.1:
2 of 6 10/5/2015 12:58 PM Entity 1.2: If yes, please disclose for each position (add additional entities if necessary): Entity 1.2: Entity 1.3: If yes, please disclose for each position (add additional entities if necessary): Entity 1.3: Item 2: Check if you or an immediate family member serves as a consultant or advisor within the past two years to an entity having an investment, licensing, or other commercial interest in any drugs, goods, or services that are the subject of the matter under consideration. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 2.1: If yes, please disclose for each position (add additional entities if necessary): Entity 2.1: Entity 2.2: If yes, please disclose for each position (add additional entities if necessary): Entity 2.2: Entity 2.3: If yes, please disclose for each position (add additional entities if necessary): Entity 2.3: Item 3: Check if you or an immediate family member has or previously had in the last two years any ownership interest in a start-up company, the stock of which is not publicly traded, or in any publicly traded company (except when invested in a diversified fund not controlled by you or an immediate family member) in an entity having an investment, licensing, or other commercial interest in a drug or other service or product which is the subject under consideration. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 3.1: If yes, please disclose for each position (add additional entities if necessary): Entity 3.1: Entity 3.2: If yes, please disclose for each position (add additional entities if necessary): Entity 3.2:
3 of 6 10/5/2015 12:58 PM Entity 3.3: If yes, please disclose for each position (add additional entities if necessary): Entity 3.3: Item 4: Check if honoraria have been paid directly to you or an immediate family member within the last two years by an entity having an investment, licensing or other commercial interest in the drugs, products, or services which are the subject of the abstract or activity. Honoraria paid by independent institutions or organizations, such as IASLC, financially supported by the entity with a commercial interest do not have to be declared if the institution or organization selection process was independent of the financial support. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 4.1: If yes, please disclose for each position (add additional entities if necessary): Entity 4.1: Entity 4.2: If yes, please disclose for each position (add additional entities if necessary): Entity 4.2: Entity 4.3: If yes, please disclose for each position (add additional entities if necessary): Entity 4.3: Item 5: Check if you or an immediate family member or your institution has received payments in connection with the conduct of the clinical research projects in question provided by the trial sponsor or agents employed by the sponsor. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 5.1: If yes, please disclose for each position (add additional entities if necessary): Entity 5.1: Entity 5.2: If yes, please disclose for each position (add additional entities if necessary): Entity 5.2: Entity 5.3: If yes, please disclose for each position (add additional entities if necessary): Entity 5.3:
4 of 6 10/5/2015 12:58 PM Item 6: Check if you or an immediate family member has provided expert testimony in a legal or regulatory setting, such as a malpractice case or FDA hearing, relating to the drugs, products, or services which are the subject matter of the abstract. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 6.1: If yes, please disclose for each position (add additional entities if necessary): Entity 6.1: Entity 6.2: If yes, please disclose for each position (add additional entities if necessary): Entity 6.2: Entity 6.3: If yes, please disclose for each position (add additional entities if necessary): Entity 6.3: Item 7: Check if you or an immediate family member received trips, travel, gifts, or other in-kind payments not directly related to research activities which totaled more than $100 and were received within the past two years from an entity having an investment, licensing, or other commercial interest in the drugs, products, or other services which are the subject matter under consideration or from an entity having an investment, licensing or other commercial interest in any of the drugs or other products or services which compete with any of the drugs, products, or services which are the subject matter under consideration (excluded from this disclosure are research-related cost and travel). If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 7.1: If yes, please disclose for each position (add additional entities if necessary): Entity 7.1: Entity 7.2: If yes, please disclose for each position (add additional entities if necessary): Entity 7.2: Entity 7.3: If yes, please disclose for each position (add additional entities if necessary): Entity 7.3: Item 8: Check if you or an immediate family member have or had in the past two years any patents or patents pending involving an entity having an investment, licensing, or other commercial interest in a drug or other service or product which is related to the subject under consideration. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary.
5 of 6 10/5/2015 12:58 PM Entity 8.1: If yes, please disclose for each position (add additional entities if necessary): Entity 8.1: Entity 8.2: If yes, please disclose for each position (add additional entities if necessary): Entity 8.2: Entity 8.3: If yes, please disclose for each position (add additional entities if necessary): Entity 8.3: Item 9: Check if you or an immediate family member in the past ten years received trips, travel, gifts, or other in-kind payments not directly related to research activities, research funding or other funding in an entity having an investment, licensing, or other commercial interest in tobacco or tobacco products. Tobacco industry funding is defined as funding directly or indirectly (e.g. through foundations) provided. This does not include funding that was obtained as a result of legal action against the tobacco industry or taxation of that industry and its products or from governmental regulatory agencies (See Appendix 1). If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Entity 9.1: If yes, please disclose for each position (add additional entities if necessary): Entity 9.1: Entity 9.2: If yes, please disclose for each position (add additional entities if necessary): Entity 9.2: Entity 9.3: If yes, please disclose for each position (add additional entities if necessary): Entity 9.3: Item 10: Ethical Research Standards. As the senior author, I certify that any prospective research reported has been conducted in accordance with appropriate ethical standards such as the Declaration of Helsinki or the United States "Common Rule". If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary. Item 11: Additional Disclosure (ONLY for IASLC Board of Directors and Key Employees): Board Members and Officers are also required to disclose relationships with any entity in which they hold an employment, leadership, compensation, or ownership interest, including relationships with non-profit entities and entities that are not oncology-related. Disclosure under the Corporate Policy covers employers, stocks, leadership positions in other societies, and leadership positions in or compensation from journals, disclosure of physician services, mutual funds, or blind trusts. If yes, please disclose for each position below. If you have more than three disclosures, please write them in on each page, or attach additional pages if necessary., I have a relationship with a non-profit entity or non-oncology related entity., I do not have a relationship with a non-profit entity or non-oncology related entity.
6 of 6 10/5/2015 12:58 PM Entity 11.1: If yes, please disclose for each position (add additional entities if necessary): Entity 11.1: Entity 11.2: If yes, please disclose for each position (add additional entities if necessary): Entity 11.2: Entity 11.3: If yes, please disclose for each position (add additional entities if necessary): Entity 11.3: Please enter any additional comments or additional disclosures here, if necessary: Verification By checking this box, I acknowledge that the information entered is true and correct. By typing/signing my full name into this box below, I hereby certify that I have answered the disclosure information contained in this form honestly and completely. NOTE: Thank you, please submit to IASLC (membership@iaslc.org) or contact IASLC if you have any questions.