ANYONE INVOLVED WITH THE CONTENT OF THE CME ACTIVITY MUST SIGN THIS FORM
(Dept. chairs, committee members, residents, fellows, nurses, presenters, etc.)
SUNY Downstate Medical Center endorses the Guidelines of the American Medical Association and the Standards of the Accreditation Council for Continuing Medical Education. Therefore, faculty or anyone involved with the presentation content for a CME activity must disclose to participants the presence of any relationships with commercial companies (healthcare related). All relevant financial relationships of any amount include receiving (from a company) research grants, consultancies, honorarium and travel, or other benefits or having self-managed equity in a company.

ACCME current definition reads" “A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.” Individuals with substantive conflicts of interest cannot plan or speak. Faculties are also expected to openly disclose any off-label, experimental, or investigational use of drugs or devices discussed in their presentation. Financial relationships of your spouse or partner, which you are aware of, for this purpose, are considered yours. Therefore, if applicable, disclosure of the relevant financial relationships of the spouses or partners of everyone in a position to control CME content is also needed for compliance.

An individual who refuses 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 (ACCME Standard 2.3.

1. Date

Date
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2. Please enter your demographic information

3. Degree/credentials:

4. Title

DISCLOSURE OF FINANCIAL RELATIONSHIPS
Within the past twelve months, I and/or my spouse/significant other have received support from or had a relationship with a/the following commercial interests (indicate all that apply). Disclosure should include relationships in any amount.

7. Do you have any disclosures?

T