25110 AMSSM Annual Meeting Mitigation of Financial Relationships Form

(Verbatim per the ACCME) ... determine whether each person’s financial relationships with ineligible companies are relevant to the content of the education you are planning. Financial relationships are relevant if the following three conditions are met for the prospective person who will control content of the education:

A financial relationship, in any amount, exists between the person in control of content and an ineligible company.
The content of the education is related to the products of an ineligible company with whom the person has a financial relationship.
The financial relationship existed during the past 24 months.

Determine which mechanism appropriately resolves the specific financial conflict and indicate how the mitigation was conducted. If a financial relationship cannot be mitigated, the person with the relationship cannot control content of the accredited continuing education or credit may not be awarded for the content presented by said individual.
The ACCME asks that you please provide your rationale for your decision.

1 Start 2 Complete

Name of individual with reported financial relationship *

Title of Presentation *

Date of Presentation *

Month

Day

Year

Role(s) of the individual in the accredited continuing education activity *

check all that apply

Role(s) of the individual in the accredited continuing education activity Other...

The following mechanisms were used to mitigate a planner's financial relationships

The relationship with the ineligible company ended, thus mitigating the relationship.

A peer review of the person's planning decisions was conducted by person with no financial relationships.

Limit his/her planning decisions to content unrelated to products or services of the ineligble company.

Other...

The following mechanisms were used to mitigate a planner's financial relationships Other...

The following mechanisms were used to mitigate Speaker financial relationships

Best available evidence is documented to support recommendations.

The relationship with the ineligible entity ended, thus mitigating the financial relationship.

A peer review of the content was conducted.

Limit his/her content to data and information while other faculty members addressed the implications and make recommendations.

Another speaker participated in content development to ensure fair and balanced content.

The content assigned was changed so the content no longer relates to the financial relationship disclosed.

The content is not related to to any product or service of the ineligble company.

Other...

The following mechanisms were used to mitigate Speaker financial relationships Other...

Rationale *

Per the ACCME, please provide the rationale for your decision.

The control over content was changed by

Upon peer review of content, no further actions required

Another individual was selected to provide the content

Focus of content was altered to resolve the financial conflict of interest

Limited the person's content to reporting scientific discovery with no practice recommendations

Signature *

I attest that I have conducted the resolution of financial conflict of interest process to ensure fair and balanced content in accredited continuing education. e-signature below.

Date *

Month

Day

Year

Leave this field blank