Disclosure Form – FamMed Forum

DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS FOR CONTINUING EDUCATION

Financial Disclosure and Agreement Form (2021 Master Form)

We are committed to presenting CME activities that promote improvements or quality in health care and are developed free of the control of ineligible companies (formerly known as a commercial interest). It is our policy to ensure that our activities are balanced, independent, objective, scientific, and in compliance with regulatory requirements. Anyone who is in a position to control the content of a CME presentation (course directors, faculty, planning committees, etc.) is expected to disclose all financial relationships with ineligible companies.* The information listed on this form will be used to assess and mitigate any potential conflict of interest you may have and will be disclosed to the audience of the CME activity. Faculty/planners who refuse to disclose will be disqualified from participating in this CME activity.

*Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Providers of clinical services directly to patients are not considered to be an ineligible company.

- Step 1 of 5

Title of CME Activity: *

Name With Credentials *

First

Last

Make sure you add your professional credentials (MD, DO, MPH, etc) to your LAST NAME, separated by commas.

Title *

Email *

Confirm Email

Phone

Role(s): Check All that Apply *

Planner/Core Faculty
Reviewer
Course Director
Moderator/Teacher/Author
Other

Other (Please Describe) *

Title of Presentation: (NA if not applicable) *

Within the past 24 months, I have received support from or had a relationship with the following ineligible companies (indicate all that apply). There is no minimum financial threshold; individuals must disclose all financial relationships with ineligible companies, regardless of the amount. *

No
Yes (If yes, provide complete information below)

Ineligible Company 1

Ineligible Company #1 Name *

Company name

Please select all that apply to Ineligible Company #1 *

Speakers Bureau	Consultant/Advisor	Stock Ownership*	Research Grant**	Employment Affiliation	Royalty/Patents
Item #1 Speakers Bureau	Item #1 Consultant/Advisor	Item #1 Stock Ownership*	Item #1 Research Grant**	Item #1 Employment Affiliation	Item #1 Royalty/Patents

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

Do you wish to add information for another ineligible company? *

Ineligible Company 2

Ineligible Company #2 Name *

Company name

Please select all that apply to Ineligible Company #2 *

Speakers Bureau	Consultant/Advisor	Stock Ownership*	Research Grant**	Employment Affiliation	Royalty/Patents
Item #1 Speakers Bureau	Item #1 Consultant/Advisor	Item #1 Stock Ownership*	Item #1 Research Grant**	Item #1 Employment Affiliation	Item #1 Royalty/Patents

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

Do you wish to add information for another ineligible company? *

Ineligible Company 3

Ineligible Company #3 Name *

Company name

Please select all that apply to Ineligible Company #3 *

Speakers Bureau	Consultant/Advisor	Stock Ownership*	Research Grant**	Employment Affiliation	Royalty/Patents
Item #1 Speakers Bureau	Item #1 Consultant/Advisor	Item #1 Stock Ownership*	Item #1 Research Grant**	Item #1 Employment Affiliation	Item #1 Royalty/Patents

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

Do you wish to add information for another ineligible company? *

Ineligible Company 4

Ineligible Company #4 Name *

Company name

Please select all that apply to Ineligible Company #4 *

Speakers Bureau	Consultant/Advisor	Stock Ownership*	Research Grant**	Employment Affiliation	Royalty/Patents
Item #1 Speakers Bureau	Item #1 Consultant/Advisor	Item #1 Stock Ownership*	Item #1 Research Grant**	Item #1 Employment Affiliation	Item #1 Royalty/Patents

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

Do you wish to add information for another ineligible company? *

Ineligible Company 5

Ineligible Company #5 Name *

Company name

Please select all that apply to Ineligible Company #5 *

Speakers Bureau	Consultant/Advisor	Stock Ownership*	Research Grant**	Employment Affiliation	Royalty/Patents
Item #1 Speakers Bureau	Item #1 Consultant/Advisor	Item #1 Stock Ownership*	Item #1 Research Grant**	Item #1 Employment Affiliation	Item #1 Royalty/Patents

* not including stocks owned in a managed portfolio

**include only grants in which you are the listed PI

Please describe any additional relevant disclosure below. *

If none, please submit N/A

In the past 24 months, have you given any presentations on behalf of an ineligible company? *

If yes, provide complete information below *

I will be using slides, scripts, or other teaching material that were provided from an ineligible company *

If yes, provide complete information below *

Speaker/Planner Agreement

I ATTEST TO THE FOLLOWING STATEMENTS

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 ineligible companies will not influence or bias my presentation and/or planning of the CME activity. *

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. *

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

I AGREE TO:

Submit my presentation to the CME office as indicated in my letter of agreement to allow for appropriate peer review and duplication in the course syllabus. *

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. *

If requested, provide appropriate peer-reviewed journal references which support clinical or practice recommendations. *

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

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

Ensure that use and reproduction of the materials or information used in my presentation will not violate any third party’s copyrights or other property rights. To the extent that copyrighted or trade secret materials are used, reproduced, or displayed within my presentation, I have obtained written permission to use, reproduce, and distribute such materials from the copyright owner. (Please note that the author of an article is not necessarily the copyright holder of the article.) *

Allow my handout materials/slide set to be distributed electronically to program participants in a pdf format. Distribution may include email, CD, flash drive, and/or download from a website or mobile app. *

Typing my name in the space above indicates that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided on page 1 of this form will be shared with learners prior to their engagement in this CME activity. *

Date *

Phone