Per various continuing education accreditation requirements, those in control of content must disclose financial relationships with ACCME defined commercial interest such a pharmaceutical companies, biomedical device companies and other commercial organizations that manufacture, distribute, and/or marketing healthcare products.

If you indicate on this form that you have a financial relationship with commercial interests, you are asked to discuss this with the Activity Director as to how reach a resolution to the conflict of interest.

Should you have a financial relationship to disclose, please identify the:

Commercial Interest: any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Providers of clinical service directly to patients are not considered to be commercial interests.

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (i.e., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

Role(s): Speakers Bureau, Owner, employment, management position, independent contractor (including contracted research). Consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities (please specify).

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Any additional disclosures and/or any details you can provide about how your work with the commercial interest(S) does or does not relate to the content of your presentation will greatly help the Office of Continuing & Professional Education with the process of resolving any real or perceived conflict(s) of interest and approving your participation in content development.
I have carefully read and considered each item in this form and I have completed it to the best of my ability.
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