DISCLOSURE AND CONFLICT-OF-INTEREST REVIEW

FOR SPEAKERS AND AUTHORS

The current regulations of the Accreditation Council for Continuing Medical Education (ACCME) require that, in addition to the usual disclosures, an assessment (and if necessary, resolution) of the potential for a conflict-of-interest is made in advance of a CME activity certified for Category 1 credit.

If a conflict-of-interest is identified, resolution of the conflict-of- interest must also be made in advance of announcements and advertising for the CME activity. To fulfill these requirements, the CME-sponsoring institution requests that you complete and submit the following questionnaire as soon as possible to the Office of CME, Chicago Medical School, 3333 Green Bay Road, North Chicago, IL 60064. The presentations of speakers and authors that decline to submit the requested information are not eligible for certification for Category 1 CME credit and the speakers (or authors) may become ineligible for honoraria and expenses.

Submission may be done by mail, fax (847/578-3320), phone (847/578-3341) or email to Elsa Kurien (). Disclosure questionnaires may be accessed on-line at the Office of CME web page, downloaded, and submitted as an attached file to the above email address or faxed to the Office of CME.

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PLEASE CHECK OFF ALL RELEVANT BOXES

Note that reasonable honoraria, support for travel, lodging or meals, and positive responses to one or more of the other questions do not necessarily indicate a conflict-of-interest. Also Note that we consider the relevant financial relationships of your spouse/partner that you are aware of to be yours.

1. z I will ¨ (I will not ¨) be receiving an honorarium for this CME activity.

2. z I will ¨ (I will not ¨) be receiving support for travel and/or lodging and/or meals for this CME activity.

3. z ¨ YES, I (or my spouse/partner) have had within the past 12 months any financial or business relationship with a commercial interest . A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. [Check where appropriate and insert name of the commercial interest]: [If you answered “Yes” to Question 3, you must answer Questions 5 AND Question 6.]

I am ¨ (or had been ¨) a recipient of monetary or other research support from:

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I am ¨ (or had been ¨) a paid consultant for: ______

I am ¨ (or had been ¨) a full-time ¨ (or part-time ¨) employee of: ______

I am ¨ (or had been ¨) listed on a speakers’ list for: ______

______.

I am ¨ (or had been ¨) a paid ¨ (or unpaid ¨) member of an advisory or similar board for: ______

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I am ¨ (or had been ¨) a member of the Board of Trustees of: ______

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¨ Other type of relationship [please describe and note if current or within the past 12 months - examples include ownership interest, royalties, and intellectual property rights]: ______

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4. z ¨ NO, I (or my spouse/partner) have not had within the past 12 months any financial or other business relationship as defined in question 3 with a commercial interest. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

5. z I ¨ WILL, ¨ WILL NOT refer to any products marketed by the commercial interests listed above.

z If Yes, the product to which I will refer will be identified:

¨ Only by its generic name

¨ By its proprietary (trade) name but with the concurrent mention of the proprietary names of similar products of other manufacturers

¨ By its proprietary (trade) name, without concurrent mention of similar competitor products

¨ By its proprietary (trade) name [there are no similar competitor products]

6. z ¨ I WILL, ¨ WILL NOT be recommending any of these products.

If Yes, the recommendation will be based:

¨ Exclusively on data and/or clinical experience not generated by the manufacturer or derived from manufacturer-sponsored studies.

¨ The recommendation will be based on data and/or clinical experience most of which were not generated by the manufacturer or derived from manufacturer-sponsored studies.

¨ The recommendation will be based on data and/or clinical experience, most of which were generated by the manufacturer or derived from manufacturer-sponsored studies.

¨ The recommendation will be based exclusively on data and/or clinical experience generated by the manufacturer or derived from manufacturer-sponsored studies.

REMINDER: If you answered “Yes” to Question 3, you must answer Questions 5 AND Question 6.

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Print Name Signature

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Name of the CME Activity

Revised on January 14, 2014