As a provider approved by the Accreditation Council for Continuing Medical Education (ACCME), The University of Utah School of Medicine Continuing Medical Education Office (UUCME) requires disclosure of the existence of relevant financial relationships with commercial interests from any individual in a position to control the content of a CME activity. Individuals who refuse to disclose relevant financial relationships or refuse to attest to the statements at the end of this form will be disqualified from all aspects of associated CME activities. Everyone in a position to control the content of a CME activity must disclose to UUCME and to the learners; all his/her relevant financial relationships and all potential conflicts must be resolved PRIOR to the activity.

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* 1. Your Name

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* 2. CME Activity Title

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* 3. Date of Activity

Date

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* 5. Title of your presentation

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* 6. What is your role in this activity? (check all that apply)

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