Financial Disclosure Form

Title of CME Activity: *

Title of Presentation: (NA if not applicable) *

Name With Credentials *

First

Last

Make sure you add your professional credentials (MD, DO, MPH, etc) to your LAST NAME, separated by commas.

Email *

Email

Confirm Email

Phone

Role(s): Check All that Apply *

Other (Please Describe) *

There is no minimum financial threshold; individuals must disclose all financial relationships with ineligible companies, regardless of the amount. Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed.
Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

Within the past 24 months, I have received support from or had a relationship with the following ineligible companies (indicate all that apply). There is no minimum financial threshold; individuals must disclose all financial relationships with ineligible companies, regardless of the amount. *

No
Yes (If yes, provide complete information below)

Ineligible Company 1

Under ACCME's Standards for Integrity and Independence, ineligible companies are those companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Ineligible Company #1 Name *

Company name

Please select all that apply to Ineligible Company #1 *

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

1) Speakers Bureau - Has this relationship ended? *

Yes
No

2) Consultant/Advisor - Has this relationship ended? *

Yes
No

3) Stock Ownership - Has this relationship ended? *

Yes
No

4) Research Grant - Has this relationship ended? *

Yes
No

5) Employment Affiliation - Has this relationship ended? *

Yes
No

6) Royalty/Patents - Has this relationship ended? *

Yes
No

Do you wish to add information for another ineligible company? *

Yes
No

Ineligible Company 2

Ineligible Company #2 Name *

Company name

Please select all that apply to Ineligible Company #2 *

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

1) Speakers Bureau - Has this relationship ended? (Company #2) *

Yes
No

2) Consultant/Advisor - Has this relationship ended? (Company #2) *

Yes
No

3) Stock Ownership - Has this relationship ended? (Company #2) *

Yes
No

4) Research Grant - Has this relationship ended? (Company #2) *

Yes
No

5) Employment Affiliation - Has this relationship ended? (Company #2) *

Yes
No

6) Royalty/Patents - Has this relationship ended? (Company #2) *

Yes
No

Do you wish to add information for another ineligible company? *

Yes
No

Ineligible Company 3

Ineligible Company #3 Name *

Company name

Please select all that apply to Ineligible Company #3 *

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

1) Speakers Bureau - Has this relationship ended? (Company #3) *

Yes
No

2) Consultant/Advisor - Has this relationship ended? (Company #3) *

Yes
No

3) Stock Ownership - Has this relationship ended? (Company #3) *

Yes
No

4) Research Grant - Has this relationship ended? (Company #3) *

Yes
No

5) Employment Affiliation - Has this relationship ended? (Company #3) *

Yes
No

6) Royalty/Patents - Has this relationship ended? (Company #3) *

Yes
No

Do you wish to add information for another ineligible company? *

Yes
No

Ineligible Company 4

Ineligible Company #4 Name *

Company name

Please select all that apply to Ineligible Company #4 *

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

1) Speakers Bureau - Has this relationship ended? (Company #4) *

Yes
No

2) Consultant/Advisor - Has this relationship ended? (Company #4) *

Yes
No

3) Stock Ownership - Has this relationship ended? (Company #4) *

Yes
No

4) Research Grant - Has this relationship ended? (Company #4) *

Yes
No

5) Employment Affiliation - Has this relationship ended? (Company #4) *

Yes
No

6) Royalty/Patents - Has this relationship ended? (Company #4) *

Yes
No

Do you wish to add information for another ineligible company? *

Yes
No

Ineligible Company 5

Ineligible Company #5 Name *

Company name

Please select all that apply to Ineligible Company #5 *

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

1) Speakers Bureau - Has this relationship ended? (Company #5) *

Yes
No

2) Consultant/Advisor - Has this relationship ended? (Company #5) *

Yes
No

3) Stock Ownership - Has this relationship ended? (Company #5) *

Yes
No

4) Research Grant - Has this relationship ended? (Company #5) *

Yes
No

5) Employment Affiliation - Has this relationship ended? (Company #5) *

Yes
No

6) Royalty/Patents - Has this relationship ended? (Company #5) *

Yes
No

Please describe any additional relevant disclosure below. *

If none, please submit N/A. If you need to report additional companies, please contact us.

I ATTEST TO THE FOLLOWING STATEMENTS

I understand that the information presented to the learner must be unbiased, scientifically balanced, and based on best available evidence and best practices in medicine. I agree to present all reasonable clinical alternatives when making practice recommendations. I attest that relationships with ineligible companies will not influence or bias my presentation and/or planning of the CME activity. *

Yes
No

All-scientific research referred to, reported, or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection, and analysis. *

Yes
No

I attest that I will not accept any payment or reimbursement for this presentation directly from any ineligible company. I understand that all payments and reimbursements must be made by the accredited provider or authorized educational partner. *

Yes
No

I AGREE TO:

Submit my presentation to the CME office as indicated in my letter of agreement to allow for appropriate peer review and duplication in the course syllabus. *

Yes
No

Avoid the use of trade names in my presentation. If I determine that it is important to clarify via the use of trade names, trade names from all available companies should be included, not just trade names from a single company. *

Yes
No

If requested, provide appropriate peer-reviewed journal references which support clinical or practice recommendations. *

Yes
No

Disclose to the program audience when products/services are not labeled for the use under discussion or when the products are still under investigation. *

Yes
No

Comply with patient confidentiality requirements as outlined in the Health Insurance Portability and Accountability Act (HIPAA) *

Yes
No

Ensure that use and reproduction of the materials or information used in my presentation will not violate any third party’s copyrights or other property rights. To the extent that copyrighted or trade secret materials are used, reproduced, or displayed within my presentation, I have obtained written permission to use, reproduce, and distribute such materials from the copyright owner. (Please note that the author of an article is not necessarily the copyright holder of the article.) *

Yes
No

Allow my handout materials/slide set to be distributed electronically to program participants in a pdf format. Distribution may include email, CD, flash drive, and/or download from a website or mobile app. *

Yes
No

Typing my name in the space above indicates that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided on page 1 of this form will be shared with learners prior to their engagement in this CME activity. *

Date *