CME Disclosure Form

 
ANYONE INVOLVED WITH THE CONTENT OF THE CME ACTIVITY MUST SIGN THIS FORM
(Dept. chairs, committee members, residents, fellows, nurses, presenters, etc.)
SUNY Downstate Medical Center endorses the Guidelines of the American Medical Association and the Standards of the Accreditation Council for Continuing Medical Education. Therefore, faculty or anyone involved with the presentation content for a CME activity must disclose to participants the presence of any relationships with commercial companies (healthcare related). All relevant financial relationships of any amount include receiving (from a company) research grants, consultancies, honorarium and travel, or other benefits or having self-managed equity in a company.

ACCME current definition reads" “A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.” Individuals with substantive conflicts of interest cannot plan or speak. Faculties are also expected to openly disclose any off-label, experimental, or investigational use of drugs or devices discussed in their presentation. Financial relationships of your spouse or partner, which you are aware of, for this purpose, are considered yours. Therefore, if applicable, disclosure of the relevant financial relationships of the spouses or partners of everyone in a position to control CME content is also needed for compliance.

An individual who refuses to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity (ACCME Standard 2.3.
1. Date
MM DD YYYY
Date
/
/
2. Please enter your demographic information
3. Degree/credentials:
4. Title
5. Which institution are you affiliated with?
Institution
Choose or add in other
DISCLOSURE OF FINANCIAL RELATIONSHIPS
Within the past twelve months, I and/or my spouse/significant other have received support from or had a relationship with a/the following commercial interests (indicate all that apply). Disclosure should include relationships in any amount.
6. Do you have any disclosures?
7. Commercial Interest (if yes above, please complete information)
8. If you plan to discuss a drug or medical device that has not been approved by the FDA, please describe.
Fair Balance, Independent Content Validation, Level of Evidence. I attest to the following:
9. I understand that the information presented to the learner must be unbiased, scientifically balanced, and based on best available evidence and best practices in medicine. I agree to present all reasonable clinical alternatives when making practice recommendations. I attest that relationships with commercial interests will not influence or bias my presentation and/or planning of the CME activity.
10. All scientific research referred to, reported, or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection, and analysis.
11. I attest that I will not accept any payment or reimbursement for this presentation directly from any commercial interest. I understand that all payments and reimbursements must be made by the accredited provider or authorized educational partner.
I agree to:
12. Avoid the use of trade names in my presentation. If I determine that it is important to clarify via the use of trade names, trade names from all available companies should be included, not just trade names from a single company.
13. If requested, provide appropriate peer-reviewed journal references which support clinical or practice recommendations. I understand that my CME presentation may be evaluated by participants for fair balance (e.g. degree of commercial bias) and that enduring materials (if applicable) will be peer-reviewed for fair balance and validation of content and may be edited accordingly.
14. Disclose to the program audience when products/services are not labeled for the use under discussion or when the products are still under investigation.
15. Comply with patient confidentiality requirements as outlined in the Health Insurance Portability and Accountability Act (HIPAA)
16. Obtain the necessary copyright permission(s) if any portion of my CME activity materials that I prepare is not my original work or for which I do not hold the copyright.
17. Enter a brief description of your presentation.
18. Learning Objectives –
What will the participant be able to do after viewing your presentation? List at least 3 expected learning outcomes in terms of knowledge, skills, attitudes and professional practice.
You may email your CV and/or Slide presentation to ocme@downstate.edu
Entering your name in the signature textbox below constitutes an electronic signature.
19. Signature
Powered by SurveyMonkey
Check out our sample surveys and create your own now!