Disclosure Form - Standards for Integrity and Independence in CME

Disclosure Form and Resolution of Conflict of Interest

Course Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any ineligible company related to the subject matter of the educational activity. Per ARMA requirements, persons who fail to sign and return this form are not eligible to be involved with this activity.

Question Title

* 1. Declaration

I understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).

Electronic Signature

Date

Email (never shared)

Question Title

* 2. Annual Disclosure for:

Planner (planning committee, staff involved in choosing topics, faculty or content)

Teacher, Instructor, Faculty

Author, Writer

Reviewer

Other

Question Title

* 3. CME Activity or Activities you participate in:

Committee Meetings

Tumor Board

Grand Rounds

Live Symposium/Conference

Journal Club

Process Improvement

Question Title

* 4. Year or Date of CME Activity:

Dignity Health-EV must ensure balance, independence, objectivity and scientific rigor in its educational activities. List the names of proprietary entities of ineligible companies (definition: those whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients.) with which you have, or have had, a relevant financial relationship* within the past 24 months.

Question Title

* 5. With respect to this CME activity (check one):

No, I do not have a relevant financial relationship with an ineligible company

Yes, I do have a relevant financial relationship with an ineligible company

Yes, but the relationship has ended

Question Title

* 6. Enter the Nature of Financial Relationship and Company Name
Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or names investigator even if that individuals institution received the research grant and manages the funds.

Question Title

* 1. DeclarationI understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).

Question Title

* 2. Annual Disclosure for:

Question Title

* 3. CME Activity or Activities you participate in:

Question Title

* 4. Year or Date of CME Activity:

Question Title

* 5. With respect to this CME activity (check one):

Question Title

* 1. Declaration

I understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).