Conflict of Interest Disclosure

Criteria for Conflict of Interest

All persons in the position to control the content of an education activity or manuscript are required to disclose all relevant financial relationships in any amount occurring within the past 12 months with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients. Failure or refusal to disclose relevant financial relationships will disqualify the participant from involvement in the CME activity or from manuscript publication. Disclosure of financial relationships includes both yourself and your spouse/domestic partner.

Identified conflicts of interest will be resolved prior to maunscript publication or an educational activity being delivered to learners through one of the following mechanisms 1) altering the financial relationship with the commercial interest, 2) altering the individual’s control over CME content about the products or services of the commercial interest, and/or 3) validating the activity or manuscript content through independent peer review.

Persons in the control of, or responsibility for, the development management, or presentation of the CME activity or manuscript are also required to disclose any discussions of off label/unapproved uses of drugs or devices.

Learners will be asked to evaluate whether there is bias in the planning or presentation of the activity.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Relationships with government agencies (e.g. the NIH) and organizations that do not produce health or medical products or services relating to patient care do not have to be disclosed.

Click here for additional disclosure term definitions.

Declaration

1. All the recommendations involving clinical medicine in a CME activity or manuscript are based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindication in the care of patients.

2. All scientific research referred to, reported or used in CME or manuscript preparation that supports or justifies a patient care recommendation complies with generally accepted standards of experimental design, data collection and analysis.

3. I will uphold academic standards to insure balance, independence, objectivity and scientific rigor.

4. I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPPAA).

Additional information may be requested to resolve any conflict of interest.

Activity or Manuscript Title *

Today's Date * +

Speaker or Author Name *

Email Address *

Do you (or your spouse/partner) have financial relationships to report? *

Yes

Please indicate the company name(s) in each corresponding box for which a financial relationship exists.

Disclosure of relevant financial relationships includes both yourself and your spouse/domestic partner.

Type of Financial Relationship

	Indicate Applicable Manufacturer(s)
Formal Advisor (i.e., scientific boards, review panels, board membership)	Indicate Applicable Manufacturer(s)
Research Activities	Indicate Applicable Manufacturer(s)
Speaker’s Bureau	Indicate Applicable Manufacturer(s)
Full-time/Part-time employment	Indicate Applicable Manufacturer(s)
Consultant	Indicate Applicable Manufacturer(s)
Ownership Interest (stocks, stock options, or other ownership interest)	Indicate Applicable Manufacturer(s)
Other (please specify):	Indicate Applicable Manufacturer(s)

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation or manuscript. *

Yes

Drugs or products I will reference are: *