Individual’s prospective role(s) in education (choose all that apply)
(i.e. planning committee, staff involved in choosing topics, faculty or content)

To be Completed by Planner, Faculty, or Others Why May Control Educational Content

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships, regardless of the potential relevance of each relationship to the education.

  1. Enter the Name of Ineligible Company - An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
  2. Enter the Nature of Financial Relationship - Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed: diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.
  3. Has the Relationship Ended? - If the financial relationship existed during the last 24 months, but has now ended, please check the box in the column. This will help the education staff determine if any mitigation steps need to be taken.

By adding your initials below, you are stating "I do not have any financial relationships with any ineligible companies".

By typing your name below, you agree that you are signing this form electronically, and that your electronic signature is the legal equivalent of your manual signature. You also acknowledge that you have read and agree with the CME activity requirements.

I do hereby attest that the information submitted above is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may result in withdrawal of CME/CE credit for the entire educational activity.