Policy Committee Meeting 12.4.23

Will you reference a specific company/product in your presentation? Yes No If you answered yes to the above, what company/product will you be referencing? *

* Please note, it is the OMA standard that if you reference or promote a company or product, you must discuss three additional comparable companies or products. If you answered yes to the above, which three companies/products will you be addressing?

I represent and warrant to OMA that I have disclosed every ineligible company or other relationship required to be disclosed under the criteria set forth above. I will promptly update my disclosures by giving written notice to the OMA program manager if my circumstances change between the date on which I sign this disclosure and the date of my deliberations. I grant OMA permission to disclose information regarding my ineligible companies and other relationships in the form and manner it deems appropriate. When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose, is discussed during an educational activity, OMA will require the speaker to disclose that the product is not labeled for the use under discussion or that the product is still investigational. I do not anticipate discussing unlabeled or investigational uses of any commercial product in this educational activity. I anticipate discussing the following unlabeled or investigational use/s of the following product/s: Product(s): Unlabeled use to be discussed:

Are you now under any investigation by any state and/or federal regulatory agencies concerning your medical or professional license?

No Yes

If yes, state the disposition of proceedings:

Please provide your medical or professional license number and issuing state:

ACCEPTANCE OF TERMS AND CONDITIONS This Agreement constitutes the entire agreement between the parties, and supersedes any and all prior agreements or understandings, written or oral, between them. No other promises or agreements shall be binding upon the parties with respect to this subject matter unless contained in this Agreement or separately agreed to in writing and signed by an authorized representative of each of the parties. I certify that the information I have provided is true and complete to the best of my knowledge. I understand that relevant financial relationships with any commercial company whose product(s) I may discuss in my education activity presentation(s) will be listed in materials for accredited activities. ACCEPTED AND AGREED TO BY:

Speaker Signature

OMA Signature

Date

Date