Financial Disclosure and Agreement Form (2022 Master Form - 2-5-22)
We are committed to presenting CME activities that promote improvements or quality in health care and are developed free of the control of ineligible companies (formerly known as a commercial interest). It is our policy to ensure that our activities are balanced, independent, objective, scientific, and in compliance with regulatory requirements. Anyone who is in a position to control the content of a CME presentation (course directors, faculty, planning committees, etc.) is expected to disclose all financial relationships with ineligible companies.* The information listed on this form will be used to assess and mitigate any potential conflict of interest you may have and will be disclosed to the audience of the CME activity. Faculty/planners who refuse to disclose will be disqualified from participating in this CME activity.

*Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Providers of clinical services directly to patients are not considered to be an ineligible company.
Make sure you add your professional credentials (MD, DO, MPH, etc) to your LAST NAME, separated by commas.

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.