Disclosure Statement
This Statement must be completed and read for the record by everyone that will be speaking at today’s meeting. (This includes scheduled public speakers, invited guests and members of the public who will speak during the open public comment period.)
Name: _________________________________________________________
Occupation: ____________________________________________________
Place of Work: _________________________________________________
Speaking on behalf of: _________________________________________
Topic: __________________________________________________________
Financial Interests
Do you or any member of your immediate family own stock or have another formal financial interest in any company, including internet or e-commerce organizations, that develops, manufactures, distributes and/or markets consulting, evidence reviews or analyses, or other services related to topic of discussion today.
Yes ❏ No ❏
Have you received financial support from such companies? (This includes speaking fees, salaries, grants and other support.)
Yes ❏ No ❏
If yes, please explain:___________________________________________________
Who paid for your transportation and/or related expenses for today’s meeting?
_________________________________________________________________________
Other Conflicts
Do you currently serve on, or previously served on, any other advisory committees or panels that considered the topic of _______________before the CAC/Open Meeting today? (This includes government panels.)
Yes ❏ No ❏
If yes, please explain:___________________________________________________
Were you contacted by any party prior to this meeting to discuss today’s topic?
Yes ❏ No ❏
If yes, please explain:___________________________________________________
Please list the source of any commercial research obtained or utilized in support of your LCDs position. (If none, please state “none”
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Consent
This meeting is being recorded. By your attendance, you are giving consent to the use and distribution of your name, likeness and voice during the meeting. You are also giving consent to the use and distribution of any personally identifiable information that you or others may disclose about you during today’s meeting. Please do not disclose personal health information.
I certify that the above statements are accurate and true.
Signature__________________________________________________________________
Date _______________________________________________________________________