Revised March, 2014
Disclosure Declaration
The University of Connecticut School of Medicine requires that all planners, speakers, or authors of CME activities complete this form for every CME activity in which they are involved
1. Name of Person Completing Form:2. Institutional Affiliation: / UCHC
3. Title of CME Activity:
4. Your Role in CME Activity: / X / Planner / Speaker or Author
Please review the following information before responding to the questions below:
Circumstances create a conflict of interest when an individual has an opportunity to influence continuing medical education (CME) content about products or services of a commercial interest (e.g., pharmaceutical company, medical device manufacturer) with which she/he has a financial relationship. A “commercial interest” is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Financial relationships are those 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 where the institution gets the grant and manages the funds and the person is the principal or named investigator on the grant), membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. When a person divests her/himself of a relationship with a commercial entity, it is no longer considered a conflict of interest, but it must be disclosed to the learners for 12 months. The University of Connecticut School of Medicine considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. Conflict of interest applies to any planners, speakers, or authors who are involved in the planning, implementation, or evaluation of the CME activity.
5. Do you, a spouse, or partner currently have (or within the past twelve months had) a financial relationship with one or more commercial interests that relates in any way to this CME activity?
No (If “no,” please skip to the next question.)Yes (If “yes,” please continue completing this section.)
If you answered “yes,” please provide the following additional information:
Name of Person with Financial Relationship:Name of Commercial Interest:
Exact Nature of Financial Relationship (including time frame and product names, if relevant):
Please provide additional sheets, if necessary, listing all relevant financial relationships.
6. For Speakers or Authors Only: Will your presentation or material mention any off-label, unlabeled, or investigational use of products or devices?
Yes (If “yes,” please continue completing this section.)
If “yes,” list the names of any products or devices about which you will be discussing such use:
7. Signature Section
For all parties: I verify that the above information is complete and accurate. For Speakers and Authors: I acknowledge that my presentation and/or materials must provide a balanced view of the therapeutic options. When discussing off-label, unlabeled, or investigational uses of a commercial product, these uses will be identified as such. I will use generic names of medications whenever possible. When I use trade names, I will include those of other companies that are on the market.
Signature: / Date:For Activity Directors Only (Please complete entire section below):
1. Did the person completing this form answer “yes” to question 5?
No (If “No,” please stop here.)Yes (If “yes,” please move to the next question.)
2. Does this disclosure represent an actual conflict of interest?
No (If “No,” please check the box that applies and sign at the bottom):
The activity director determined that the financial relationship is outside the area of the content of the program.The activity director determined that the financial relationship ceased to exist 12 or more months ago.
Other, please explain:
Yes (If an actual conflict of interest exists, please check the box below that describes how you resolved the conflict of interest (i.e., what safeguards you will have in place) to prevent the insertion of commercial bias):
The activity director will restrict the speaker’s presentation or the planner’s involvement to areas outside the area of conflict.The activity director peer-reviewed the content of the presentation ensure that no commercial bias exists.
Other, please explain:
Please remember that any conflict of interest and safeguards in place must be disclosed to participants (e.g., promotional brochure) in advance of the CME activity.
Activity Director’s Signature / Date