REMINDER: Financial Disclosures are good for 24 months from date of completion.

To be Completed by Planner, Reviewer, Faculty, or Others Who May Control Educational Content

We are looking forward to having the opportunity to include you as a planner/faculty/reviewer in our accredited continuing education activity.

Why am I receiving this communication?

UT Health Science Center San Antonio Office of CME is accredited by the Accreditation Council for Continuing Medical Education (ACCME). We appreciate your help in partnering with us to follow accreditation guidelines and help us create high-quality education that is independent of industry influence. In order to participate as a person who will be able to control the educational content of this accredited CE activity, we ask that you disclose all financial relationships with any ineligible companies that you have had over the past 24 months. We define INELIGIBLE COMPANIES (formerly Commercial Support) as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; you must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask you to disclose regardless of whether you view the financial relationships as relevant to the education. For more information on the Standards for Integrity and Independence in Accredited Continuing Education, please visit

Why do we collect this information?

Since healthcare professionals serve as the trusted authorities when advising patients, they must protect their learning environment from industry influence to ensure they remain true to their ethical commitments. Many healthcare professionals have financial relationships with ineligible companies. By identifying and mitigating relevant financial relationships, we work together to create a protected space to learn, teach, and engage in scientific discourse free from influence from organizations that may have an incentive to insert commercial bias into education.

What are the next steps in this process?

After we receive your disclosure information, we will review it to determine whether your financial relationships are relevant to the education. Please note: the identification of relevant financial relationships does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity.

To help us meet these expectations, please use the form we have provided to share all financial relationships you have had with ineligible companies during the past 24 months. This information is necessary in order for us to be able to move to the next steps in planning this continuing education activity.

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* 1. Your Name:

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* 2. Credentials: (MD, DO, DPM, RN, PA, etc)

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* 3. You are a (select all that apply):

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* 4. Name of CME Activity: (e.g. Heart Rhythm Focus 2021, Pediatric Grand Rounds, AYA Tumor Board)

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* 5. Activity Date:

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* 6. Title of your presentation(s) (Not the title of the activity at which you are presenting):