Faculty Disclosure Of Commercial Interest {QME 119}

Administrative Director, Division of Workers' Compensation ATTN.: Medical Unit P. O. Box 71010 Oakland, CA 94612 FACULTY DISCLOSURE OF COMMERCIAL INTEREST As an education provider accredited by the Administrative Director, (Education Provider's Name) must ensure objectivity in its educational activities. Having an interest or ownership in a business does not prevent a physician from making a presentation, but the relationship must be disclosed to the audience, in accordance with Administrative Director's regulations. Please complete the information below. TITLE OF COURSE: DATE: NAME OF FACULTY: TITLE OF PRESENTATION: (Check one) [] Neither I, nor my family members, have any past or present financial arrangements or affiliations with any business involved in the products/services which will be discussed at this symposium. (Skip to signature.) [ ] I, or one or more of my family members, have a financial interest/arrangement or affiliation with the following businesses which offer products/services that I will discuss at this symposium. Name(s) of Business(es) Affiliation/Financial Interest Grants/Research Support Consultant Speaker's Bureau Major Stock Shareholder Other Financial or Material Interest Signature Date QME Form 119 (rev. February 2009) American LegalNet, Inc. www.FormsWorkflow.com