Annual Conference & Exhibit Moderator COI Review

Onsite Moderator Conflict of Interest Review Form

Annual Conference Moderators are required to complete this form for each session they moderate immediately after the session concludes. If you have major COI concerns during the session, please text Kelsey Kind, the APHON Education Manager at 847.375.6485

"*" indicates required fields

Moderator Name*

First Last

Session Date

Session Start Time

Session Title

As a result of moderating/monitoring the above session, I am able to comment on the following:

Speaker(s) disclosed relevant financial relationships at the beginning of the session.

Yes

No: The following speaker(s) did not comply

List speaker names if applicable

"not" Disclosure did include the use of a trade name or product-group message.*

Yes

No: Please describe below

Please provide detail if you responded no to the previous question.

The session was free from marketing activities, either before, during, or after the presentation.*

Yes

No: Please describe below

Please provide detail if you responded no to the previous question.

Presentations were free from commercial bias for/or against any product.*

Yes

No: The following presentation(s) may have contained commercial bias (describe):

Please provide detail if you responded no to the previous question.

Additional Comments

Name

This field is for validation purposes and should be left unchanged.