Joint Provider- Disclosure of Relevant Financial Relationships (AKA Vested Interest)

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* 1. Disclosure

Name: *

Activity Title *

Presentation Date

Email Address:

Phone Number:

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* 2. Indicate your role in this activity

Participant in case discussion/presentations

Presenter

Author

Course Director

Moderator

Planning Committee Member

Other (please specify)

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* 3. Commercial Interest Funding this program (If known)

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* 4. Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with the manufacturer of the products or services that will be presented (planner) or in your presentation (faculty/author)? If NO skip to question 8.

Yes

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* 5. Nature of Relevant Financial Relationship

Pharma/Device Employee

Grants/Research support recipient

Pharma/Device Board Member

Advisor or Review Panel member

Consultant

Independent Contractor

Stock Shareholder (excluding mutual funds)

Speaker’s Bureau

Honorarium recipient directly from Pharma/Device Co.

Royalty recipient

Holder of Intellectual Property Rights

List Companies if applicable

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* 6. Presenter/Authors

	Yes	No	N/A
I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature.	I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature. Yes	I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature. No	I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature. N/A
I will refrain from making recommendations, regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and /or research findings.	I will refrain from making recommendations, regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and /or research findings. Yes	I will refrain from making recommendations, regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and /or research findings. No	I will refrain from making recommendations, regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and /or research findings. N/A
I will recommend an alternative presenter for this topic for the planning committee’s consideration.	I will recommend an alternative presenter for this topic for the planning committee’s consideration. Yes	I will recommend an alternative presenter for this topic for the planning committee’s consideration. No	I will recommend an alternative presenter for this topic for the planning committee’s consideration. N/A
I will submit my talk in advance to allow for adequate peer review.	I will submit my talk in advance to allow for adequate peer review. Yes	I will submit my talk in advance to allow for adequate peer review. No	I will submit my talk in advance to allow for adequate peer review. N/A
I will have divested myself of this financial relationship.	I will have divested myself of this financial relationship. Yes	I will have divested myself of this financial relationship. No	I will have divested myself of this financial relationship. N/A

Other (please specify)

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* 7. Planners/Committee Members

	Yes	No	N/A
To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.	To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias. Yes	To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias. No	To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias. N/A
I will recuse myself from planning activity content in which I have a conflict of interest.	I will recuse myself from planning activity content in which I have a conflict of interest. Yes	I will recuse myself from planning activity content in which I have a conflict of interest. No	I will recuse myself from planning activity content in which I have a conflict of interest. N/A

Other (please specify)

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* 8. Unlabeled/un-approved uses

There will be a discussion of unlabeled uses, and I will disclose this during my presentation.

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* 9. Declaration

I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development or presentation of this CME activity. In addition I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Glossary of Terms

Commercial Interest

The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. For more information, visit www.accme.org.

Financial relationships

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, 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, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant financial relationships

ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

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.