Maryland Orthopaedic Association

2010 Financial Disclosure Form

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

MARYLAND ORTHOPAEDIC ASSOCIATION
110 West Road, Suite 227
Towson, MD 21204
410-847-9300

Mandatory Financial Disclosure Statement

Below is a statement that will apply to you in connection with your participation in Maryland Orthopaedic Association’s 69th Annual Meeting, April 24, 2010.

If you have a financial interest or other relationship with a commercial company related directly or indirectly with the MOA's 69th Annual Meeting, answer "Yes." Also include the name of the commercial company. Your disclosure will be listed in the MOA 2010 Final Program/Course Syllabus.

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 MOA 69th 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 *
the Primary Author/Speaker
a Co-Author

Primary Author/Speaker Name

Abstract Title *

Please enter the text from the image above: