REMINDER: Financial Disclosures are good for one year from date of completion.

FOR SPEAKERS, PLANNERS AND REVIEWERS OF CONTINUING MEDICAL EDUCATION ACTIVITIES
As an approved provider by the Accreditation Council for Continuing Medical Education (ACCME) it is the policy of the Office of Continuing Medical Education to ensure the highest integrity, scientific objectivity and absence of bias. It also holds providers of CME responsible for collecting information from an individual who is in a position to control the content of a CME activity and resolving those conflicts prior to the commencement of the CME activity. The intent of the disclosure is to acknowledge any relevant financial relationships with commercial interests and to ensure that all conflicts are resolved prior to the activity.

CRITERIA FOR DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS WITH COMMERCIAL INTEREST.

A commercial interest is defined as any proprietary entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients, with the exemption of non-profit or government organizations (e.g., the NIH) and non-health care related companies.

- An individual who is in a position to control the content of a CME activity are required to disclose ALL relevant financial relationships with commercial interests associated with this CME activity of any amount (or in-kind) within the PAST 12 MONTHS ONLY.
- Principle investigators must report research funding relationships below under "contracted research" even if those funds came to an institution.
- You must disclose ALL relevant financial relationships you and your spouse or life partner has with applicable manufacturers.This includes but is not limited to any marketing advice you and your spouse or life partner provide to applicable manufacturers.
- YOU DO NOT HAVE TO DISCLOSE if you have received honoraria (or fee-for-service) or consulting funds from a CME provider, even though those funds may have been provided through an educational grant from a commercial interest.

An individual who refuses to disclose relevant financial relationships with commercial interests will be disqualified from being a speaker or planning committee member.

* 1. Your Name:

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

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

* 4. To properly record your disclosure, our office must know the complete title of the CME activity (not your presentation title) to which you have been invited to speak (i.e., Family Practice Review Course, Medicine Grand Rounds, Pediatric Grand Rounds Laboratory Medicine Report, Trauma M&M).

* 5. Date of your presentation:

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

* 7. Please provide 2-3 objectives for your presentation(s):

* 8. Are you UTHSCSA Faculty? This question is related to biographical information. Since the Office of CME has access to faculty profiles our office will no longer request this from UTHSCSA Faculty.

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