EUROPEAN UNION OF MEDICAL SPECIALISTS The European Accreditation Council for Continuing Medical Education EACCME Institution of the UEMSaisbl

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E U R O P E A N U N I O N O F M ED I C A L S P E C I A L I S T S

T h e 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 f o r

C o n t i n u i n g M e d i c a l E d u c a t i o n – E A C C M E ®

I n s t i t u t i o n o f t h e U E M Sa i s b l AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE- 1050 BRUSSELS F +32 2 640 37 30 www.eaccme.eu accreditation@uems.net

UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

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

Conflict of Interest Disclosure Form

(to be completed by faculty and scientific/organising committee members) NAME : F.J.M. Broekmans

AFFILIATION: University Medical Center Utrecht

In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the EACCME”, 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

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

Type of affiliation / financial interest Name of commercial company

Member of the external advisory board Consultancy work:

Educational activities:

Strategic cooperation on automated AMH assay development:

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U N I O N E U R O P É E N N E D E S M É D E C I N S S P É C I A L I S T E S

E U R O P E A N U N I O N O F M E D I C A L S P E C I A L I S T S

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

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EUROPEAN

UNION

OF

MEDICAL

SPECIALISTS

The

Eur opean

Accreditation

Council

f or

Continuing

Medi cal

Education

–

EACCME®

I n s t i t u t i o n

o f

t h e

U E M S

a i s b l

AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE‐ 1050 BRUSSELS F +32 2 640 37 30 www.eaccme.eu accreditation@uems.net

UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE‐1050 Bruxelles

Conflict

of

Interest

Disclosure

Form

(to be completed by faculty and scientific/organising committee members)

NAME : Stratis kolibianakis

AFFILIATION: Aristotle University of Thessaloniki Greece

In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the

EACCME”, 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

Type of affiliation / financial interest Name of commercial company

Receipt of grants/research supports: Receipt of honoraria or consultation fees: Participation in a company sponsored speaker’s bureau:

Stock shareholder:

Spouse/partner:

Other support (please specify):

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U N I O N

E U R O P É E N N E

D E S

M É D E C I N S

S P É C I A L I S T E S

E U R O P E A N

U N I O N

O F

M E D I C A L

S P E C I A L I S T S

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 info@uems.net Signature: Date: 6/01/2015

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E U R O P E A N U N I O N O F M ED I C A L S P E C I A L I S T S

T h e 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 f o r

C o n t i n u i n g M e d i c a l E d u c a t i o n – E A C C M E ®

Conflict of Interest Disclosure Form

(to be completed by faculty and scientific/organising committee members) NAME : F.J.M. Broekmans

AFFILIATION: University Medical Center Utrecht

DISCLOSURE

Member of the external advisory board Consultancy work:

Educational activities:

Strategic cooperation on automated AMH assay development:

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U N I O N E U R O P É E N N E D E S M É D E C I N S S P É C I A L I S T E S

E U R O P E A N U N I O N O F M E D I C A L S P E C I A L I S T S

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

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(13)

EUROPEAN

UNION

OF

MEDICAL

SPECIALISTS

The

Eur opean

Accreditation

Council

f or

Continuing

Medi cal

Education

–

EACCME®

I n s t i t u t i o n

o f

t h e

U E M S

a i s b l

AVENUE DE LA COURONNE, 20 T +32 2 649 51 64 BE‐ 1050 BRUSSELS F +32 2 640 37 30 www.eaccme.eu accreditation@uems.net

UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE‐1050 Bruxelles

Conflict

of

Interest

Disclosure

Form

NAME : Stratis kolibianakis

AFFILIATION: Aristotle University of Thessaloniki Greece

In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the

EACCME”, 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

Type of affiliation / financial interest Name of commercial company

Receipt of grants/research supports: Receipt of honoraria or consultation fees: Participation in a company sponsored speaker’s bureau:

Stock shareholder:

Spouse/partner:

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U N I O N

E U R O P É E N N E

D E S

M É D E C I N S

S P É C I A L I S T E S

E U R O P E A N

U N I O N

O F

M E D I C A L

S P E C I A L I S T S

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 info@uems.net Signature: Date: 6/01/2015

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E U R O P E A N U N I O N O F M ED I C A L S P E C I A L I S T S

T h e 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 f o r

C o n t i n u i n g M e d i c a l E d u c a t i o n – E A C C M E ®

Conflict of Interest Disclosure Form

NAME : Juha Tapanainen

AFFILIATION: University of Helsinki and Helsinki University Central Hospital

DISCLOSURE

X I have no potential conflict of interest to report

Receipt of grants/research supports: Receipt of honoraria or consultation fees:

Participation in a company sponsored speaker’s bureau: Stock shareholder:

Spouse/partner:

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E U R O P E A N U N I O N O F M ED I C A L S P E C I A L I S T S

T h e 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 f o r

C o n t i n u i n g M e d i c a l E d u c a t i o n – E A C C M E ®

Conflict of Interest Disclosure Form

NAME : Juha Tapanainen

AFFILIATION: University of Helsinki and Helsinki University Central Hospital

DISCLOSURE

X I have no potential conflict of interest to report

Receipt of grants/research supports: Receipt of honoraria or consultation fees:

Participation in a company sponsored speaker’s bureau: Stock shareholder:

Spouse/partner:

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