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CME Faculty/Planner Disclosure

ANYONE INVOLVED WITH THE CONTENT OF THE CME ACTIVITY MUST SIGN THIS FORM

(Dept. chairs, committee members, residents, fellows, nurses, presenters, etc.)

 

                I understand that SUNY Downstate Medical Center endorses the Guidelines of the American Medical Association and the Standards of the Accreditation Council for Continuing Medical Education.  Therefore, faculty or anyone involved with the presentation content for a CME activity must disclose to participants the presence of any relationships with commercial companies (healthcare related).

                All financial relationships of any amount include receiving (from a company) research grants, consultancies, honorarium and travel, or other benefits or having self-managed equity in a company.  Individuals with substantive conflicts of interest cannot plan or speak. Faculties are also expected to openly disclose any off-label, experimental, or investigational use of drugs or devices discussed in their presentation. Financial relationships of your spouse or partner, which you are aware of, for this purpose, are considered yours.

                An individual who refuses to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity (ACCME Standard 2.3).

 

Activity Title

Title/topic of Presentation

Date
Check One:
Author Course Director Faculty Moderator Planning Committee Reviewer

First Name

Last Name

Degree and credentials

Title

Organization

Address

City/State/Zip

Phone

Email


DISCLOSURE OF FINANCIAL RELATIONSHIPS
1. Within the past twelve months, I and/or my spouse/significant other have received support from or had a relationship with a/the following commercial interests (indicate all that apply). Disclosure should include relationships in any amount.

No

Yes (if Yes, provide complete information below)

 

Commercial Interest

Speakers bureau

Consultant, advisor

Stock ownership*

Research grant**

Employment affiliation

Royalties, patents

* not including stocks owned in a managed portfolio

Please describe any additional relevant disclosure below:


2.  I will discuss a drug or medical device that has not been approved by the FDA.

No

Yes (Describe Below)

 

3. I will be using slides, scripts, or other teaching material that were provided from a commercial source

No

 

Yes (Describe Below)

 

4. Content Validation/Resolution of Conflicts of Interest

I attest to the following:

Yes

No

I understand that the information presented to the learner must be unbiased, scientifically balanced, and based on best available evidence and best practices in medicine. I agree to present all reasonable clinical alternatives when making practice recommendations. I attest that relationships with commercial interests will not influence or bias my presentation and/or planning of the CME activity.

Yes

No

All scientific research referred to, reported, or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection, and analysis.

Yes

No

I attest that I will not accept any payment or reimbursement for this presentation directly from any commercial interest. I understand that all payments and reimbursements must be made by the accredited provider or authorized educational partner.

I agree to:

Yes

No

Avoid the use of trade names in my presentation. If I determine that it is important to clarify via the use of trade names, trade names from all available companies should be included, not just trade names from a single company.

Yes

No

If requested, provide appropriate peer-reviewed journal references which support clinical or practice recommendations. I understand that my CME presentation may be evaluated by participants for fair balance (e.g. degree of commercial bias) and that enduring materials (if applicable) will be peer-reviewed for fair balance and validation of content and may be edited accordingly.

Yes

No

Disclose to the program audience when products/services are not labeled for the use under discussion or when the products are still under investigation.

Yes

No

Comply with patient confidentiality requirements as outlined in the Health Insurance Portability and Accountability Act (HIPAA)

Yes

No

Obtain the necessary copyright permission(s) if any portion of my CME activity materials that I prepare is not my original work or for which I do not hold the copyright.
5. Abstract of Presentation – Brief description of your presentation

6. Learning Objectives –

List at least 3 expected learning outcomes in terms of knowledge, skills, attitudes and professional practice.

What will the participant be able to do after viewing your presentation?

Electronic Signature (Please type your name)
You may email your CV and/or Slide presentation to ocme@downstate.edu