All CME Disclosure Form 7 for 2017/2018  (Revised 8/2017)

FORM 7 Disclosure of Relevant Financial Relationships By Speakers, Authors, Editors, Moderators, Teachers, Planners, and Committee Members of CME Activities

The intent of this disclosure is to allow the Greenville Health System the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its CME activities.

All Speakers, Authors, Editors, Moderators, Teachers, Planners, and Committee Members of Greenville Health System activities are expected to disclose to Greenville Health System any relevant financial relationships with any commercial interest that produces health care goods or services related to the content of any educational activity in which they are involved.

An individual who refuses to disclose relevant financial relationships will be disqualified from being any of the following: a Speaker, an Author, an Editor, a Moderator, a Teacher, a Planner, or a Committee Member and cannot have control of nor responsibility for  the development, management, presentation or evaluation of the CME activity.

Definition of Terms

Conflict of interest: Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

Commercial interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients. The ACCME does not consider providers of clinical services directly to patients to be commercial interests.

Financial relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honorarium, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and his/her spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.

Question Title

* Have you read the above statement?

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* This Disclosure is for Participation in any/all CME Annual and/or Regularly Scheduled Series (GHS Topic, Case, Journal Club, Enduring, Simulation Based) Activities.

Dates of Activities: September 1, 2017  through August 31, 2018. It is only necessary to complete this form once in this time span unless your disclosure changes.

Do you or your spouse/partner (past 12 months) have relevant financial relationships with proprietary entities producing health care goods or services related to the content of this activity? (Please check the correct box below.)