Commercial Independence in Continuing Medical Education Evaluation

Evaluation and CME Credit Claim Form

PLEASE NOTE: Your answers to the 2 quiz questions below will not impact your ability to claim CME credit.

Question Title

True or false: when disclosing financial relationships, individuals may determine for themselves when their relationship is related to the CME content.

True

False

Question Title

True or false: In most cases, employees or owners of ineligible companies (a.k.a. commercial interests) have unresolvable financial relationships and must be excluded from controlling any aspect of a CME activity.

True

False

Question Title

After viewing the video, please rate your ability to:

	Poor		Good		Excellent
Gather disclosure information from all in control of CME content	Gather disclosure information from all in control of CME content Poor	Gather disclosure information from all in control of CME content	Gather disclosure information from all in control of CME content Good	Gather disclosure information from all in control of CME content	Gather disclosure information from all in control of CME content Excellent
Identify relevant financial relationships	Identify relevant financial relationships Poor	Identify relevant financial relationships	Identify relevant financial relationships Good	Identify relevant financial relationships	Identify relevant financial relationships Excellent
Mitigate relevant financial relationships appropriate to the person’s role(s)	Mitigate relevant financial relationships appropriate to the person’s role(s) Poor	Mitigate relevant financial relationships appropriate to the person’s role(s)	Mitigate relevant financial relationships appropriate to the person’s role(s) Good	Mitigate relevant financial relationships appropriate to the person’s role(s)	Mitigate relevant financial relationships appropriate to the person’s role(s) Excellent
Disclose the presence or absence of relevant financial relationships prior to the education	Disclose the presence or absence of relevant financial relationships prior to the education Poor	Disclose the presence or absence of relevant financial relationships prior to the education	Disclose the presence or absence of relevant financial relationships prior to the education Good	Disclose the presence or absence of relevant financial relationships prior to the education	Disclose the presence or absence of relevant financial relationships prior to the education Excellent

Question Title

An “ineligible company,” also known as a "commercial interest,” is defined as any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients. Among the exemptions to this definition are government organizations, non-health care related companies and non-profit organizations that do not advocate for commercial interests. Did you perceive any bias toward a "commercial interest" in this activity?

Yes

If yes, please explain:

Question Title

What barriers do you face in implementing what you learned in this activity?

Question Title

To claim CME credit, please provide your contact information below.

First Name: *

Last Name: *

Credentials: *

Address:

City/Town:

State:

ZIP:

Country:

Email Address: *

Company:

Physicians: The number of credits claimed equals the number of AMA PRA Category 1 Credits™ awarded, with one hour of participation equaling one AMA PRA Category 1 Credit™. Physicians should claim credit in 15 minute (i.e. 0.25 credit) increments.This enduring material was designated for 0.25 AMA PRA Category 1 Credit™.

All other attendees: Please complete this form so that we may verify your participation in this activity, which was designated for 0.25 AMA PRA Category 1 Credit™.

Question Title

Attestation & Credits Claimed

I attest that I viewed "Commercial Independence in Continuing Medical Education" enduring material.

Number of credits claimed (up to 0.25):