Disclosure of Relevant Financial Relationships and Attestation
Faculty/Teachers/Moderators/Authors
In accordance with the 2004 ACCME Standards for Commercial Support, The University of Texas MD Anderson Cancer Center has implemented a process whereby everyone who is in a position to control the content of an educational activity must disclose all relevant financial relationships with any commercial interest (see attachment for definitions). Per ACCME, a conflict of interest exists if you have listed any relevant relationships below. All disclosure forms will be reviewed by the program chair(s) prior to the activity. Please provide the following information in order for us to be able to move to the next steps in planning this CME activity. If you refuse to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of this CME activity.
Name of CME/Activity: NNECOS 2015 Annual Meeting and Palliative Care Symposium
Program Code: Date of Activity: 10/23-10/24/15
Activity Location: Portland Marriott at Sable Oaks, Portland, ME
Program Chair(s): Sunil Patel, MD, Tracey Weisberg, MD
Faculty/Teacher/Moderator/Author:
First MI Last Highest Degree(s)
Title of Presentation:
Please list the names of any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, with the exemption of providers of clinical service directly to patients, with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose, we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
I. / I do not have any relevant financial relationships with any commercial interests.Nature of Relevant Financial Relationship
(include all of those that apply) / Commercial Interest
Provide Name of Company/Companies
Grant or research support
Paid consultant
Speaker’s Bureau
Employment
Honoraria
Membership on advisory committees or review panels, board membership, etc.
Ownership Interest (e.g., stocks, stock options or other ownership interests, excluding diversified mutual funds)
Other relevant financial or material interests
(please specify)
My conflict of interest/relationships with the above-listed commercial interest(s) will be resolved in the following manner:
□ Relationship is not relevant to the presentation content
□ Pros and cons of therapeutic options will be discussed
□ Multiple therapeutic options/protocols will be discussed
□ Focus of presentation will be away from relationships/conflicts identified
□ Content of presentation will be based on best available evidence
□ My presentation will be limited to a report without recommendations
□ Other: (please specify)
Name of CME Activity:
Program Code:
II. Investigational or off-label use of a product
My presentation(s) will NOT include discussion of investigational or off-label use of a product.
My presentation(s) WILL include discussion of investigational or off-label use of a product.
III. Please list 2-3 educational objectives for your presentation OR summarize your presentation via an attachment. (Not applicable for program moderators)
1.
2.
3.
IV. I agree my presentation(s) will
(A) Contribute to quality and/or improvement in healthcare and align with what is in the best interests of patients and public health and not a specific proprietary business interest;
(B) Adhere to the ACCME’s content validation statements. Specifically,
· All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients;
· All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis;
(C) Include only scientific or generic names (not trade names) in referring to products. Should it be necessary to use a trade name, then the trade names of all similar products or those within a class will be used.
(D) Include a summary of my disclosure of conflicts of interest (template provided)
(E) If presentation discusses investigational or off-label use of a product, the audience will be advised to confirm reimbursement eligibility before submitting any claim for unapproved use, dosage or combination.
Please contact the Program Chair(s) if you do not feel your presentation can meet these standards.
V. I will not accept any compensation directly or indirectly from a commercial interest for participating in this activity.
VI. Signature: Date:
ACTUAL SIGNATURE REQUIRED PLEASE
Your cooperation in complying with these guidelines is appreciated. Please make as many copies as necessary to list all relevant affiliations or interests. Should you have any questions, please call CME/Conference Management at 713.792.7275. Thank you for your assistance.
Glossary of Terms
Commercial Interest
ACCME Definition: A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. (from ACCME Policy Updates, August 2007)
The ACCME does not consider providers of clinical service directly to patients to be commercial interests.
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 interest 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 in within the past 12 months that create a conflict of interest.
Conflict of Interest
When an individual’s interests are aligned with those of a commercial interest the interests of the individual are in ‘conflict’ with the interests of the public. The ACCME considers financial relationships to create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest. The potential for maintaining or increasing the value of the financial relationship with the commercial interest creates an incentive to influence the content of the CME – an incentive to insert commercial bias.
For Educational Program Planners, Speakers and Authors
Background Information
Planner Presenter/Author
Name and credentials:
Preferred address:
City , State Zip
Preferred: Phone: E-mail:
Employer and position (title):
Educational preparation (DO NOT ATTACH CURRICULUM VITAE)
(Begin with baccalaureate or other initial professional education and include postdoctoral training.)
Institution name and location (city, state) / Degree / Year of completion / Field Of Study
Planners: Please describe your qualifications to be on the planning team.
If you are nurse planner, please describe your experience in planning educational programs.
If you are the content expert, please describe your experience or education related to the topics being presented.
Presenters/Authors: Please provide a detailed description/list of your qualifications to present/author your topic, such as recent presentations, publications, pertinent work experience, training or education.
ONS Disclosure/Conflict of Interest Form for Planners, Presenters and Authors
Financial Disclosure/Conflict of InterestAccording to the ONS Position on Commercial Support, ONS General Conflict of Interest Disclosure Policy, and ANCC and ACCME standards planners/speakers/authors are required to disclose any relevant financial interests or other relationships that they or an immediate family member have had in any amount in the past 12 months with commercial entities that produce, market, resell or distribute healthcare products or services that are used on or by patients. Relevant financial relationships must be disclosed and will be shared with learners.
For the past 12 months, please indicate whether you or a member of your immediate family had a financial relationship in any amount with companies that produce, market, resell or distribute healthcare products or services that are used on or by patients (other than direct patient care).
For each type of relationship, place a check mark in the appropriate column. If you were paid for your efforts, list the name of the entity providing support and the dates of the financial relationship. If you need to provide additional information about any of the relationships you list, please use the comment area at the bottom of this table.
Type of Relationship / None / Financial relationship with you or family member / Entity Providing Support / Dates of relationship
· Employment (full- or part-time employee, independent contractor)
· Consulting fee or honorarium
· Payment for lectures, including services on speakers bureaus
· Support for travel to meetings
· Research funding
· Fees for participation in advisory or review activities
· Provision of writing assistance, medicine, equipment, or administrative support
· Payment for development of educational materials, presentations or manuscripts
· Stock or stock options
Comments:
Please type your full name in the electronic signature box. This will act as your electronic signature for this form. If you hand sign the form, also print and/or type of name as indicated below.
/ To the best of my knowledge and belief, the information reported above is true and accurate. I understand that this information will be disclosed publicly at the educational program. I further understand that the program provider reserves the right to decline to allow me to present or otherwise limit my participation in this particular activity if they believe that a significant conflict of interest exists. I agree to notify the program provider if there is any change in the information that I have provided regarding my financial relationships prior to the presentation.Signature / Date signed
Printed Full Name
Rev. 7/13