Section 1

The Society of Hospital Medicine (SHM) is accredited by the ACCME to provide CME for physicians. As such, SHM must ensure balance, independence, objectivity and scientific rigor in all its educational projects.  The purpose of this form is to assist us in identifying any conflicts of interest that may adversely impact the integrity of CME. For SHM’s full conflict of interest policy, please see the “SHM Policy for the Identification, Resolution and Disclosure of Conflict of Interest in the Creation of CME.”

The ACCME considers financial relationships to create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest (defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients).  For information on ACCME policies and definitions, please visit, Standards for Commercial Support, Standard 2.

All faculty, authors, committee members, board members, staff and anyone else that influence content creation for SHM educational activities, quality improvement program and/or resource development are required to disclose to SHM and subsequently to learners any/all relationships with commercial interests if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CME about the products or services of that commercial interest. The principal intent of this disclosure is not to prevent an individual with such relationships from participating in the activity, but to allow SHM to assess potential conflict of interest and work with you to resolve that conflict. 

If there is any uncertainty about whether or not there is a potential conflict, the individual should err on the side of full disclosure. Individuals must complete and submit this form in order to serve as faculty, authors, speakers, planning committee members or to in any way influence or create the content for this educational activity. Individuals who refuse to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity.

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* 1. Name of Activity: 

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* 2. I have read SHM's disclosure policy and I declare the following: