CONFLICT OF INTEREST REPORTING FORM FOR INSTRUCTORS, PLANNERS AND

MANAGERS OF CONTINUING MEDICAL EDUCATION ACTIVITIES

Name of Discloser:

Because CME activities are conducted in the public interest, it is important to assure the public that education received by physicians and other health care professionals through whom patient care decisions are made is conducted with the highest integrity, scientific objectivity and in the absence of bias. A conflict of interest exists when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the product or services of that commercial interest. The Accreditation Council for Continuing Medical Education (ACCME) holds providers of CME responsible for collecting information from its instructors, planners and managers of CME content and resolving those conflicts prior to the commencement of the CME activity. The intent of the conflict of interest resolution process is to assure that provider, faculty and planner financial relationships with commercial interests and resultant loyalties do not supersede the public interest in the design and delivery of continuing medical education activities for the profession.

Criteria for Disclosure of Conflicts of Interest

  • Instructors, planners and managers who affect the content of a CME activity are required to disclose to MedStar Washington Hospital Center financial relationships or relationships to products or devices they have with commercial interests of any amount over the past 12 months ONLY.
  • A commercial interest is defined as a maker or owner of a FDA-regulated drug or device.
  • Relationships with governmental agencies (e.g., the NIH) and organizations which do not make or own

FDA-regulated drugs or devices do not have to be disclosed.

  • If you have received honoraria (or fee-for-service) or consulting funds from a CME provider, even though those funds may have been provided through an educational grant from a commercial interest, YOU DO NOT HAVE TO DISCLOSE THOSE HONORARIA OR FEES.
  • You must disclose SIGNIFICANT financial relationships your spouse or life partner has with applicable manufacturers (“significant” means, for example, holder of a patent, or is employed by a manufacturer you reference, or provides marketing advice to applicable manufacturers.) Disclosure of spousal/partner information should be included in your disclosure in the table below.
  • In accordance with ACCME requirements, failure to provide disclosure information in a timely manner will result in the disqualification of the potential activity director, instructor, or planning committee member from this activity.

Please review the following statements and indicate your understanding of and willingness to comply with each statement.

If you have any questions regarding your ability to comply, please contact Melanie Mitchell at 202-877-3200 as soon as possible.

Agree / Disagree
Content for this activity, including any presentation of therapeutic options, will be well-balanced,
evidence-based and unbiased.
The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific business interest of a commercial interest.
I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with MedStar Washington Hospital Center.
I understand that MedStar Washington Hospital Center may need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.
If I am providing recommendations involving clinical medicine, they will 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 of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.
If I am discussing specific health care products or services, I will use generic names. If I need to use trade names, I will use them from several companies, and not just from any single company.
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.
If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.

Name of Discloser:

I am a/an: Activity Director Planning committee member Instructor WHC Committee member

Name of CME Activity:Date of Activity:

Within the past 12 months, have you or your spouse/partner had a financial relationship or relationship to products or devices with one or more organizations?

NO I/We have no real or apparent conflicts of interest to report

YES Please insert the financial relationships and the company names below.

Self / Spouse/
Partner / Type of Financial Relationship
WITHIN THE PAST 12 MONTHS ONLY
(from today’s date)
Include significant spousal/ partner relationships / Indicate Applicable Manufacturer(s)
WITHIN THE PAST 12 MONTHS ONLY
(Please write legibly or type the name of the commercial interest that you have a relationship with in the appropriate box below)
Salary
Royalty
Receipt of Intellectual Property Rights / Patent Holder
N/A / Consulting Fees (e.g., advisory boards)
N/A / Fees for Non-CME Services Received Directly from Commercial Supporter or their Agents (e.g., speakers bureaus)
N/A / Contracted Research
Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds)
Other : (please describe)

If you reported relationships in the chart above, will any of these relationships impact your ability to present a balance and unbiased presentation? No Yes

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

Please list name of device/drug and unlabeled/unapproved use:

By checking this box, I represent that the foregoing information is complete and truthful.

Signature*: / Date:

* Please type your name all in UPPERCASE; this will serve as your electronic signature for this form