PA Moms will try to accommodate slots based in the order applications are submitted.
Faculty Disclosure Form
A conflict of interest may exist if a faculty member of an educational activity, or spouse or partner of that
person, has financial relationships with the grantor or any commercial interest(s) that may directly impact
the content of the program. A financial relationship is defined as being a shareholder, consultant, grant
recipient, research participant, employee, and/or recipient of other financial or material support. The
participants in this CME activity must be made aware of any such financial relationship(s). All persons
who may have control over the content must fully disclose any such financial relationship.
This disclosure policy is intended to protect all parties involved from potential conflicts of interest that
may arise. AAPA assumes responsibility for resolving these conflicts of interest.
If you have no disclosures, please only complete the required items (designated with a red asterisk)
Please fill out the name of commercial interest (if applicable) to the Financial Relationships below.