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).
 

 
1 Start 2 Complete
*
*
(Click on all that apply)
*
*
I have carefully read and considered each item in this form and I have completed it to the best of my ability.
*
*
Please upload a copy of your CV.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.