Disclosure of Relevant Financial Relationships Form

Name:
Content of Activity: Deliver seminar
Date of Activity: 11-14 Sept 2014

Please complete and return this form before 30 June2014

Thank you.

In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all planning committee members, authors, and teachers involved in the development of continuing education content are required to disclose to the accredited provider their relevant financial relationships. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last twelve months with a commercial interest whose products or services are discussed in the CPE activity content over which the individual has any control.

The intent of this disclosure is not to prevent an author, writer, presenter, faculty, or consultant with a potential conflict of interest from contributing to a CPE program, but to resolve any actual conflicts and to inform learners about the relationship before the program begins.

For an individual with no relevant financial relationships, learners must be informed that no relevant financial relationship(s) exist(s).

Please answer the following questions:

  1. Does the CPE content over which you have control contain information about healthcare products or services?

Please circle:No

IfNo: please go to the next page, sign and return this form.

IfYes: please answer Question 2.

  1. Regarding the healthcare products or services that will be discussed in the CPE content over which you have control, have you had a financial relationship in any amount in the last 12 months with the manufacturers of the products or providers of the services?

Please circle:Yes orNo

IfNo: please go to the next page, sign and return this form.

IfYes: please complete the chart on the next page, then sign and return this form.

Chart to complete if yes to question 2:

Manufacturer or
Service Provider / Nature of Relationship* / I have divested myself of this relationship(circle one).
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

* E.g. Advisory or other groups funded by industry

Signature:______Date:______

Glossary of Terms

Abbreviations

ACCMECouncil for Continuing Medical Education’s

CPEContinuing Professional Education

Commercial interest

The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

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 CPE activity to include financial relationships of a spouse or partner.

Relevant financial relationships

ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CPE 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 within the past twelve months that create a conflict of interest.

Conflict of interest

Circumstances create a conflict of interest when an individual has an opportunity to affect CPE content about products or services of a commercial interest with which he/she has a financial relationship.

This information will be retained on file with the Educational Services Division and a listing will be printed in the onsite handout materials for the program. Submit completed form to Professional secretariat

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