Many healthcare professionals have financial relationships with ACCME(R) defined ineligible companies. These relationships must not be allowed to influence accredited continuing education. Financial relationships of any dollar amount are defined as relevant if the educational content is related to the business lines or products of the ineligible company. 

The Medical College of Wisconsin collects information from all planners, faculty, and others in control of educational content about all their financial relationships with ineligible companies within the prior 24 months. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. Individuals must disclose regardless of their view of the relevance of the relationship to the education. 

An ineligible company is a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

 
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Companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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In the past 24 months, have you been employed by or have ownership interest in an ineligible company (a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients)?
Name of your employer or company for which you have ownership interest.
As an employee or owner of an ineligible company; I attest that (check all that apply)
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Has this financial relationship ended?
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Has this financial relationship ended?
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Has this financial relationship ended?
Any additional disclosures and/or any details you can provide about how your work with the ineligible companies does or does not relate to the content of your presentation will greatly help the Office of Continuing Professional Development with the process of resolving any real or perceived conflict(s) of interest and approving your participation in content development. I will provide educational content (slides, handouts, etc) to the Medical College of Wisconsin prior to the start of the CME activity for review.
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I attest to the following:

The Medical College of Wisconsin's Office of Continuing Professional Development has created a process aimed to support Faculty development in their presentation skills, and ultimately, in their academic promotion. This process consists of an optional standardized CME speaker evaluation that assesses the quality of the presentation's delivery, style, and methods. Afterwards, the speaker will receive a report that includes comparison data of the Faculty speaker to other Faculty speakers within their respective clinical department that have opted to use the evaluation in the past. This report can be used in your Educator's Portfolio. The evaluation's report is provided to Faculty within 3 weeks of the evaluation's closing for the CME activity.

This is an optional opportunity that can be utilized by Faculty who present at grand rounds, conferences, workshops, and other CME accredited activities.

To view a sample evaluation, please navigate to the following page: Sample Evaluation

To request further information about this evaluation, please contact Brian Tomczyk at [email protected].

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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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