DISCLOSURE OF FINANCIAL RELATIONSHIP FORM

Name/Credentials / Click here to enter text.
TelephoneNumber: / Click here to enter text. / E-MailAddress: / Click here to enter text.
Activity Name: / Click here to enter text. / Date: / Click here to enter text.
Please indicate your role in this CME activity: / Presenter/Faculty Course Director Moderator Planning Committee
(Please check all that apply)

Purpose: Itisthepolicyofthe Indiana State Medical Association (ISMA) toensurebalance,independence,objectivityandscientificrigorinallof its sponsorededucationalactivities. Allparticipatingfaculty, coursedirectors,andplanningcommitteemembers are requiredtodisclose tothe program audienceanyfinancialrelationshipsrelatedtothesubjectmatterofcontinuingmedicaleducation(CME)activities/programs.Relationshipsofspouse/partnerwithproprietaryentitiesproducinghealthcaregoodsorservicesshouldbedisclosediftheyareofanature thatmayinfluencethe objectivity oftheindividualinapositiontocontrolthecontentofthe CMEactivity.Disclosureinformationisreviewedin advanceinordertomanageandresolveanypossibleconflictsofinterest.This information is necessary in order for us to be able to move to the next steps in planning this CME activity.

Personswhofailtoprovidethisinformationinadvanceofthecourse(allowingforadequatetimeforreview)arenoteligibletobeinvolvedinthisCMEactivity.

Participation: We are pleased that you are willing and able to participate in this CME activity, which is accredited by the ISMA. The ISMA is accredited by the Accreditation Council for Continuing Medical Education (ACCME). As such, we are required to meet the ACCME’s expectations for our practice of continuing medical education.

Step1:DisclosureofRelevantFinancialRelationships

Relevantfinancialrelationshipsarethoseinwhichanindividual(includingtheirspouse/partner)inthelast12months:

  • hashadapersonalfinancialrelationship (anyamount)withacommercialinterest, which is defined as anyentityproducing,marketing,re-selling,ordistributinghealthcaregoodsorservicesconsumedby,orusedon,patients;andwho
  • hascontrolovereducationalcontentrelatedtotheproductsand/orservicesofthecommercialinterest(s).

RegardingyourroleinthisCMEactivity(checkone):

☐No,I/wehavenorelevantpersonalfinancialrelationship.(Ifyoucheckedthisbox,skiptoStep 2)

☐Yes,I/wedohaveapersonalfinancialrelationshipwithacommercialinterestandcontrolover

educational contentrelatedtotheproductsand/orservicesofthecommercialinterest(s). (Provideinformationbelow)

NatureofFinancialRelationship / NameofCommercialInterest(s)andRelationship / Self / Spouse/Partner
☐Consultant / Click here to enter text. / ☐ / ☐ /
☐ Speaker’sBureau / Click here to enter text. / ☐ / ☐ /
☐ Grant/ResearchSupport
☐(PrincipalInvestigatororworking
directlyfor company/company’s agent) / Click here to enter text. / ☐ / ☐
☐ StockShareholder(self-managed) / Click here to enter text. / ☐ / ☐ /
☐ Honoraria / Click here to enter text. / ☐ / ☐ /
☐ Full-time/part-timeEmployee/Owner* / Click here to enter text. / ☐ / ☐ /
☐ Other(Describe): / Click here to enter text. / ☐ / ☐ /

* The ISMA PROHIBITS employees and owners of Commercial Interests from participating on any

CME PLANNING COMMITTEE and serving as presenters.

Additional information maybe requestedtoaddressanyperceivedconflict ofinterest. All identifiedconflicts ofinterestmust bemanagedandresolved inadvance of theactivityand disclosureinformationwill be sharedwith theactivityparticipants.

Step 2:Speaker DisclosureofOff-Labeland/or InvestigationalUses

Ifatanytimeduringmyeducationalactivity,Idiscussanoff-label/investigativeuseofacommercialproduct/device,IunderstandthatImustprovide disclosureofthatintent.

☐ No,Idonotintendtodiscussanoff-label/investigativeuseofacommercialproduct/device.

☐ Yes,Idointendtodiscussoff-label/investigativeuse(s)ofthefollowingcommercialproduct(s)/device(s).

Step 3: StatementsRulesofISMA/ACCMEAccreditation / Content Validation

Pleaseread thestatements/rulesofISMA/ACCME accreditation below,sign,andreturn tothe ISMA Continuing MedicalEducation Office. Ifyou haveanyquestionsregarding yourability to comply,please contact Cheryl Stearley, CME Coordinator, at317-261-2060,orby .

  • Thecontentand/orpresentationoftheinformationwith whichIam involved willpromotequality orimprovementsin healthcareandwillnotpromotea specificbusinessinterestofacommercialinterest.Contentforthis activity,including anypresentation oftherapeuticoptions,willbe well-balanced,evidence-based,andunbiased,and hasadequatejustificationfortheirindicationsandcontraindicationsinthe careofapatient.
  • Recommendationsinvolving diagnosisandtreatmentdiscussed in thepresentation are based onevidencewhich isacceptedwithintheprofession ofmedicine asadequate justificationfor theirindicationsand contraindicationin the care ofpatient.
  • Allscientific researchreferred to,reportedorusedin CME insupportofjustification ofpatientcare recommendationwillconform tothegenerally acceptedstandardsofexperimentaldesign,data collection,andanalysis.Citationsoftheworkarerecommended.
  • The content will not promote recommendations, treatment, or manners of practicing medicine that are not within the definition of CME, or known to have risks or dangers that outweigh the benefits or known to be ineffective in the treatment of patients. The content will not advocate for unscientific modalities of diagnosis or therapy.
  • Objectivesofmypresentation areconsistentwithoverallobjectivesofthecourse, andthe content is relevant to participantsneeds.
  • I have disclosed (viaDisclosureForm to ISMA)allrelevantfinancialrelationships.Iunderstand thesewillbe disclosedtotheaudience, if theyare relevant/potentiallyrelevant tothe educationalcontent.
  • I have notand willnotacceptany honoraria,additionalpaymentorreimbursementsbeyond thatwhichhasbeen agreed upondirectlywiththe ISMA.
  • I understand that ISMA CME staff will need toreviewmypresentation and/orcontentpriortothe activity,andIwillprovide educational contentand resourcesin advance,asrequested.
  • I understand thatcommercialentity corporate namesorlogosshould notappearon myslidesor handouts.
  • I understand that ISMA CME staff maybe attending theeventtoensure thatmypresentation iseducational,andnotpromotional, innature.
  • If I am discussing specifichealthcare productsorservices, Iwilluse genericnamesto the extentpossible.If I need touse tradenames, Iwilluse tradenamesfromseveralcompanieswhen available,and not justtrade namesfrom any individual company.
  • If I amdiscussingany productusethatisofflabel,Iwilldisclosethattheuse orindicationin question isnotcurrently approvedbytheFDAforlabeling oradvertising.
  • If I have beentrained orutilized bya commercialentityoritsagentasa speaker(e.g.,speaker’s bureau foranycommercialinterest),the promotionalaspectsofthe presentationwillnotbe includedinanyway withthisactivity.
  • If I am aspeakerforanycommercialinterest, thepromotionalaspectsofthis relationship willnot be includedinanywaywith thisactivity.
  • If I ampresentingresearch funded by acommercialcompany,theinformation presented willbe based on generallyacceptedscientificprinciples andmethods,andwillnotpromote the commercialinterestofthe fundingcompany.
  • If I am presenting research studies, Iwillinclude weaknessesandstrengthsofeachstudy,inaddition to harmsand benefitsofspecificproducts.Iwill also discussstudiespresenting differentconclusionsaboutthe product, if available.

Step 4: Declaration

IwillupholdtheISMA CMEstandardstoensurebalance,independence,objectivity,andscientificrigorinmyroleintheplanning,developmentorpresentationofthisCMEactivity.IunderstandthatCMEaccreditationguidelinesprohibitmefromacceptinganyreimbursement(financial,gifts,orin-kindexchange)forthispresentationfromanysourceotherthantheaccreditedCMEprovideroritseducationalpartner(orfiscalagent).

Signature/PrintedName: Date:

Ifsendingthiscompleteddocumentelectronically,pleasetypeyournameaboveandcheckthisbox:

☐ Bycheckingthisbox,Iattestthatthecompletedinformationisaccurate.Pleaseacceptthisasmysignature.

Thankyouforprovidinguswiththisinformation.

RETURN TO: Cheryl Stearley, CME Coordinator at.

Glossary of Terms as Defined by the American Council on Continuing Medical Education (ACCME)

Commercial Interest

TheACCMEdefinesa“commercialinterest”asanyentityproducing,marketing,re-selling,ordistributinghealthcaregoodsorservices,usedon,orconsumedby,patients.TheACCMEdoesnotconsiderprovidersofclinicalservicedirectlytopatientstobecommercialinterests.Formoreinformation, visit

FinancialRelationships

Financialrelationshipsarethoserelationshipsinwhichtheindividualbenefitsbyreceivingasalary,royalty,intellectualpropertyrights,consultingfee,honoraria,ownershipinterest(e.g.,stocks,stockoptionsorotherownershipinterest,excludingdiversifiedmutualfunds),orotherfinancialbenefit.Financialbenefitsareusuallyassociatedwithrolessuchasemployment,managementposition,independentcontractor(includingcontractedresearch),consulting,speakingandteaching,membershiponadvisorycommitteesorreviewpanels,boardmembership,andotheractivitiesfromwhichremunerationisreceived,orexpected.ACCMEconsidersrelationshipsofthepersoninvolvedintheCMEactivitytoincludefinancialrelationshipsofaspouseorpartner.

RelevantFinancialRelationships

ACCMEfocusesonfinancialrelationshipswithcommercialinterestsinthe12-monthperiodprecedingthetimethattheindividualisbeingaskedtoassumearolecontrollingcontentoftheCMEactivity.ACCMEhasnotsetaminimaldollaramountforrelationshipstobesignificant.Inherentinanyamountistheincentivetomaintainorincreasethevalueoftherelationship.TheACCMEdefines“’relevant’financialrelationships”asfinancialrelationshipsinanyamountoccurringwithinthepast12monthsthatcreateaconflictofinterest.

ConflictofInterest

CircumstancescreateaconflictofinterestwhenanindividualhasanopportunitytoaffectCMEcontentaboutproductsorservicesofacommercialinterestwithwhichhe/shehasafinancialrelationship. The ACCME considers “content of CME about the products or services of that commercial interest” to include content about specific agents/devices, but not necessarily about the class of agents/devices, and not necessarily content about the whole disease class in which those agents/devices are used.

RESOLUTION OF CONFLICT OF INTEREST

Step 1

/

Owners/Employees of Commercial Interest (CI)

☐ / Not an employee/owner of CI (go to Step 2)
☐ / Planning Committee employee/owner of CI (choose from below):
☐ No planning has occurred – individual is fully recused from committee
☐ Planning has occurred – activity will not be accredited
☐ / Faculty/speaker employee/owner of CI (choose from below):
☐ Faculty/speaker is not allowed to present
☐ Activity will not be accredited

Step 2

/

Conflict of Interest (COI)

☐ / No relevant financial relationship (no COI)
☐ / Potential COI – presenter (choose from below):
☐ Presentation materials reviewed to ensure fair balance, scientific objectivity and no
commercial bias
☐ Presenter will refrain from making recommendations on topics of COI
☐ All recommendations for patient care are based on peer review data
☐ Role is limited so financial relationship no longer relevant
☐ Discontinue contracted services that create financial relationship – must disclose such
relationship to audience for 12 months
☐ Individual excluded from content creation and delivery; was replaced with another presenter
☐ Activity will not be accredited
☐ / Potential COI - planner
☐ Planner recused from planning content relevant to reported COI
☐ Another non-conflicted planner will participate in planning to ensure fair balance; non-conflicted planner will review proposed content to ensure it is free from potential bias; non-conflicted planner will oversee selection of faculty