(1) LIST the names of any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months.
(2) For this purpose we consider the ’relevant’ financial relationships” as financial relationships of your or your spouse/partner in any amount occurring within the past 12 months that create a conflict of interest.
(3) Describe what you or your spouse/partner received (ex: salary, honorarium etc). Foundation for Orthopaedic Research and Education does NOT want to know how much you received.
(4) Describe your role.
(5) If no relationship exists, this information must be disclosed as well.