Disclosure Form - Standards for Integrity and Independence in CME
In compliance with Accreditation Council for Continuing Medical Education (ACCME)

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 financial relationships with any ineligible company related to the subject matter of the educational activity. Per Arizona Medical Association (ArMA) requirements, persons who fail to sign and return this form are not eligible to be involved with this activity.

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* 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)

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* 2. Annual Disclosure for:

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

Teacher, Instructor, Faculty

Author, Writer

Reviewer

Other

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* 3. CME Activity or Activities you participate in:

Committee Meetings

Tumor Board

Grand Rounds

Live Symposium/Conference

Journal Club

Process Improvement

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* 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 all 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 financial relationship* within the past 24 months. There is no minimum financial threshold. We ask that you disclose all financial relationships, regardless of the amount and regardless of the potential relevance of each relationship to the education.

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

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

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

Yes, but the relationship has ended

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* 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 named investigator even if that individuals institution received the research grant and manages the funds.

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* 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).

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* 2. Annual Disclosure for:

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* 3. CME Activity or Activities you participate in:

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* 4. Year or Date of CME Activity:

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* 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).