Financial Disclosures for all individuals who can influence or control

The Accreditation Council for Continuing Medical Education (ACCME) requires CME providers to identify and resolve all potential conflicts of interest of planners and presenters prior to a CME activity (i.e., all individuals in a position to control the content). When financially relevant relationships are disclosed, the potential conflict must be resolved. Relevant financial relationships identified on the disclosure form (including the absence of such relationships) must be conveyed to the audience prior to the beginning of the activity.

"Relevant Financial Relationships" are those in which an individual (including spouse/partner) has both:

1. a personal financial relationship
(any amount) with a commercial interest (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) in the past 12 months, whether the relationship has now ended or is currently active.

2. Control in planning or presenting educational content addressing specific products of the commercial interest (not simply a whole class of products as a group).

(No disclosures needed for relationships with non-profits, government units, or entities not producing health care goods or services.)

* 1. Address:

* 2. Credentials:

* 3. If Applicable:

Please indicate the ABSTRACT(S) you have authored :

* 4. Please select your role(s) in the educational activity:

* 5. Disclosure. Regarding my role in the CME activity listed above, currently or in the past 12 months (select one):