EACCME COI form Demoule ESICM forum Madrid · EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS) EUROPEAN...

EUROPEAN UNION OF MEDICAL SPEC IAL ISTS (UEMS)

EUROPEAN ACCRED I TAT ION COUNC I L ON CME ( EACCME® )

RUE DE L’INDUSTRIE 24, BE-‐ 1040 BRUSSELS T + 32 2 649 51 64 -‐ F + 32 2 640 37 30

https://eaccme.uems.eu -‐ [email protected]

UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 � BIC (SWIFT) BPOTBEB1 � VAT n° BE 0469.067.848

Conflict of Interest Disclosure Form

NAME : Demoule…………………………………………. AFFILIATION: Alexandre……………………………………….

In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial

or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of

the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-‐imbursement of expenses in relation to the LEE has been provided.

DISCLOSURE

I have no potential conflict of interest to report

X I have the following potential conflict(s) of interest to report

Type of affiliation / financial interest Name of commercial company

Receipt of grants/research supports: Philips, Maquet, Medtronic

Receipt of honoraria or consultation fees: Maquet, Medtronic, Baxter, Hamilton, Philips

Participation in a company sponsored speaker’s bureau:

Stock shareholder:

Spouse/partner:

Other support (please specify):

Signature: Date: 25/11/2017

E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )

RUE DE L’INDUSTRIE 24, BE- 1040 BRUSSELS T + 32 2 649 51 64 - F + 32 2 640 37 30

https://eaccme.uems.eu - [email protected]

UEMSaisbl – Union Européenne des Médecins Spécialistes IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848


NAME : …………Takeshi Yoshida………………………………. AFFILIATION: ……St. Michael Hospital………………………………….

In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.

DISCLOSURE

○,(

I have the following potential conflict(s) of interest to report



Receipt of grants/research supports:

Receipt of honoraria or consultation fees:


Stock shareholder:

Spouse/partner:



mailto:[email protected]�






NAME : Ramón Nogué Bou AFFILIATION: Universitat de Lleida, UDL · Department of Surgery


DISCLOSURE

X I have no potential conflict of interest to report






Stock shareholder:

Spouse/partner:


Signature: Ramón Nogué Bou Date: 06/12/2017







NAME : ………Oriol Roca…………………………………. AFFILIATION: …Vall d’Hebron University Hospital…………………………………….



DISCLOSURE




Receipt of honoraria or consultation fees: Hamilton Medical

Participation in a company sponsored speaker’s bureau: Fisher & Paykel

Air Liquide

Stock shareholder:

Spouse/partner:


Signature: Date: 30.11.17







NAME : MARIA PAZ FUSET CABANES AFFILIATION: HOSPITAL UNIVERSITARIO Y POLITÉCNICO LA FE. VALENCIA


DISCLOSURE







Stock shareholder:

Spouse/partner:


Signature: MARIA PAZ FUSET CABANES Date: 24/11/17


E U R O PE AN U N ION O F ME DI CA L S P E C IA L I S TS ( U EM S )

E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )





NAME : Maria Cruz martin Delgado MD Ph AFFILIATION: Hospital Universitario Torrejon Madrid, Spain

In accordance with criterion 14 of document UEMS 2016/20 “EACCME® criteria for the Accreditation of Live

Educational Events (LEEs)”, all declarations of potential or actual conflicts of interest, whether due to a financial

or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also

must be made readily available, either in printed form, with the programme of the LEE, or on the website of the

organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-

imbursement of expenses in relation to the LEE has been provided.

DISCLOSURE







Stock shareholder:

mailto:[email protected]

UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES EUROPEAN UNION OF MEDICAL SPECIALISTS

Association internationale sans but lucratif – International non-profit organisation

AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE- 1050 BRUSSELS F +32 2 640 37 30 www.uems.net [email protected]

Spouse/partner:


Signature: Maria Cruz Martin Date:30/11/2017

http://www.uems.net/


E U R O PE AN U N ION O F ME DI CA L SP E C IA L I S T S ( UEM S )






NAME : …Marcelo Amato

AFFILIATION: INCOR –Heart Institute, University of São Paulo




must be made readily available, either in printed form, with the programme of the LEE, or on the website of

the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-


DISCLOSURE




Receipt of grants/research supports: Timpel Medical S.A.



Stock shareholder:

Spouse/partner:


Signature: Date: 17th-January-2018






NAME : Luciano Gattinoni AFFILIATION: Universitätmedizin Göttingen


DISCLOSURE






Participation in a company sponsored speaker’s bureau: Masimo ; Grifols ; Linet

Stock shareholder:

Spouse/partner:


Signature: Date: 26 November 2017


E U R OP E AN U NI ON OF M E D ICA L S P E CI AL I ST S (U E M S )






NAME : Lu Chen AFFILIATION: St. Michael’s Hospital, University of Toronto




must be made readily available, either in printed form, with the programme of the LEE, or on the website of the

organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-


DISCLOSURE







Stock shareholder:

Spouse/partner:


Signature: Date: November 30, 2017


E U R O PE AN U N ION O F ME D I CA L SP E C IA L I S T S ( UEM S )




UEMSaisbl – Union Européenne des Médecins Spécialistes

IBAN BE28 0001 3283 3820 Ơ BIC (SWIFT) BPOTBEB1 Ơ VAT n° BE 0469.067.848


NAME : LLUÍS BLANCH TORRA AFFILIATION: CORPORACIÓ SANITÀRIA PARC TAULÍ







DISCLOSURE

� I have no potential conflict of interest to report

� I have the following potential conflict(s) of interest to report





Stock shareholder: 10% Better Care, S.L. (Spin Off of Corporació

Sanitària Parc Taulí)

Spouse/partner:



EUROPEANUNIONOF MEDICAL SPEC IAL ISTS (UEMS) EUROPEAN ACCRED I TAT ION COUNC I L ON CME ( EACCME® )

RUEDEL’INDUSTRIE24,BE-1040BRUSSELS

T+3226495164-F+3226403730

https://[email protected]

UEMSaisbl–UnionEuropéennedesMédecinsSpécialistes

IBANBE28000132833820ǀBIC(SWIFT)BPOTBEB1ǀVATn°BE0469.067.848

ConflictofInterestDisclosureForm

NAME:…GuillermoMAlbaiceta……………………………………….

AFFILIATION:HospitalUniversitarioCentraldeAsturias.Oviedo,Spain.……………………………………….

Inaccordancewith criterion14ofdocumentUEMS2016/20 “EACCME®criteria for theAccreditationof Live

EducationalEvents(LEEs)”,alldeclarationsofpotentialoractualconflictsofinterest,whetherduetoafinancial

orotherrelationship,mustbeprovidedtotheEACCME®uponsubmissionoftheapplication.Declarationsalso

mustbemadereadilyavailable,either inprintedform,withtheprogrammeoftheLEE,oronthewebsiteof


imbursementofexpensesinrelationtotheLEEhasbeenprovided.

DISCLOSURE

XIhavenopotentialconflictofinteresttoreport

qIhavethefollowingpotentialconflict(s)ofinteresttoreport

Typeofaffiliation/financialinterest Nameofcommercialcompany

Receiptofgrants/researchsupports:

Receiptofhonorariaorconsultationfees:

Participationinacompanysponsoredspeaker’sbureau:

Stockshareholder:

Spouse/partner:

Othersupport(pleasespecify):

Signature: Date:24-Nov-2017






NAME: GEMMA RIALP AFFILIATION: HOSPITAL SON LLATZER, PALMA DE MALLORCA. ILLES BALEARS


DISCLOSURE







Stock shareholder:

Spouse/partner:


Signature: Gemma Rialp Date: 12/02/2017


E U R OP E AN U NI ON OF M E D ICA L SPE C IAL I ST S (U EM S )






NAME : Fernando Suarez Sipmann AFFILIATION: Dept. Surgical Sciences, Hedenstierna Laboratory, Uppsala University. Uppsala, Sweden.

Department of Critical Care, Hospital Universitario de La Princesa, Madrid, Spain.







DISCLOSURE







Stock shareholder:

Spouse/partner:

Other support (please specify): I perform consultan services

for Maquet Critical Care


U NION EUR OPÉENNE DES MÉDECINS SPÉCIAL ISTES EU R OPEAN U NION OF MEDICAL SPECIAL ISTS

Association internationale sans but lucratif – International non-profit organisation

AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE- 1050 BRUSSELS F +32 2 640 37 30 www.uems.net [email protected]

Signature: Fernando Suarez Sipmann Date: 26-11-2017

http://www.uems.net/







NAME : Federico Gordo AFFILIATION: Henares University Hospital


DISCLOSURE







Stock shareholder:

Spouse/partner:









NAME : Georgopoulos Dimitrios…………………………………………. AFFILIATION: …University of Crete, Medical School…………………………………….


DISCLOSURE







Stock shareholder:

Spouse/partner:


Signature: Georgopoulos Dimitris Date: 30/11/2017







NAME : ………Daniel Talmor…………………………………. AFFILIATION: …Beth Israel Medical Center…………………………………….


DISCLOSURE





Receipt of honoraria or consultation fees:- 1. Hamilton Medical 2. Faron


Stock shareholder: Intensix

Spouse/partner:


Signature: Date: November 27 2017


E U R O P E A N U N IO N O F M E D IC A L S P E C IA L IS T S ( U E M S ) E U R O P E A N A C C R E D I T A T I O N C O U N C I L O N C M E ( E A C C M E ® )





NAME : Antonio Pesenti AFFILIATION: Department of Pathophysiology and Transplantation, University of Milan


DISCLOSURE

q I have no potential conflict of interest to report




Receipt of honoraria or consultation fees: Baxter, Maquet, Xenios


Stock shareholder:

Spouse/partner:



EACCME COI form Demoule ESICM forum Madrid · EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS) EUROPEAN...

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