Financial Interest Form

The OPS has determined that financial interest shall be disclosed in courses sponsored or co-sponsored by the OPS. Acknowledgment of financial interest will be made in the program and at the time of the presentation by projected slide and/or public announcement. All course instructors, and authors of posters are required to complete and sign the OPS Financial Interest Statement below.

For the purpose of this Financial Interest Statement, “Designated Company” means an entity related directly or indirectly to the manufacture or distribution of lenses, pharmaceuticals, medical devices or instruments, or vision care products or services commonly utilized by ophthalmologists.

State of Financial Interest

First Name

Middle Initial

Last Name

This form is submitted for the following OPS Educational Program:

Categories of Financial Interest

  1. Financial interest in a Designated Company greater than five percent (5%) of the outstanding securities of any class or Fifty-Thousand Dollars ($50,000.00).
  2. Engaged as a compensated or non-compensated consultant, advisor, or employee by a Designated Company.
  3. Received research funds from a Designated Company.
  4. Received free or discounted products in amounts not commercially available, equipment, instruments, or services other than incidentals, from a Designated Company.
  5. Received travel stipend or honorarium from a Designated Company, which is associated with my OPS presentation or poster.

I, or a member of my family, or my professional partnership or corporation, or my employer, currently have or within the preceding twelve (12) months have had a financial interest in a Designated Company, or a financial relationship or advisory capacity with any Designated Company or entity related to the following presentations and posters. For each course in which I have a financial interest as described above, the course names and the category of financial interest are listed below.

Categories Course Name

ie: 1,2,5

ie: Descriptive Interpretation of Fluorescein Angiography

 

Neither I, nor a member of my family, nor my professional partnership or corporation, nor my co-instructor(s)/coauthor(s), currently have or within the preceding twelve (12) months have had a financial interest in a Designated Company, or a financial relationship or advisory capacity with a Designated Company related to the following presentations and posters.

Course Name

 


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