Faculty Disclosure Form

Section 1: Demographic Data

Title of Educational Activity *

Educational Activity Date *

Month

Day

Year

Role in Educational Activity (check all that apply) *

Planner Examples: planning committee, staff involved in choosing topics, faculty, or content

Teacher, Instructor, Faculty

Author, Writer

Reviewer

Other...

Role in Educational Activity (check all that apply) Other...

Faculty Name *

Credentials/Degrees *

Email *

Current Employer and Position/Title *

As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence.

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance.

To be Completed by Planner, Faculty, or Others Who 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.

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.

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; 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.

Have you had any financial relationships *

Yes

No

Section 2: Financial Relationships

Relationship list *

Advisor - Enter the Name of Ineligible Company *

Advisor - Disease state *

Have any of the Advisor relationships ended? *

Yes

No

Please indicate the Advisor relationships that have ended: *

Consultant - Enter the Name of Ineligible Company *

Consultant - Disease state *

Have any of the Consultant relationships ended? *

Yes

No

Please indicate the Consultant relationships that have ended: *

Employee - Enter the Name of Ineligible Company *

Employee - Disease state *

Have any of the Employee relationships ended? *

Yes

No

Please indicate the Employee relationships that have ended: *

Executive Role - Enter the Name of Ineligible Company *

Executive Role - Disease state *

Have any of the Executive Role relationships ended? *

Yes

No

Please indicate the Executive Role relationships that have ended: *

Independent Contractor (including contracted research) - Enter the Name of Ineligible Company *

Independent Contractor (including contracted research) - Disease state *

Have any of the Independent Contractor relationships ended? *

Yes

No

Please indicate the Independent Contractor relationships that have ended: *

Individual Stocks and Stock Options - Enter the Name of Ineligible Company *

Individual Stocks and Stock Options - Disease state *

Have any of the Individual Stocks and Stock Options relationships ended? *

Yes

No

Please indicate the Individual Stocks and Stock Options relationships that have ended: *

Ownership Interest - Enter the Name of Ineligible Company *

Ownership Interest - Disease state *

Have any of the Ownership Interest relationships ended? *

Yes

No

Please indicate the Ownership Interest relationships that have ended: *

Researcher - Enter the Name of Ineligible Company *

Researcher - Disease state *

Have any of the Researcher relationships ended? *

Yes

No

Please indicate the Researcher relationships that have ended: *

Royalties or Patent Beneficiary - Enter the Name of Ineligible Company *

Royalties or Patent Beneficiary - Disease state *

Have any of the Royalties or Patent Beneficiary relationships ended? *

Yes

No

Please indicate the Royalties or Patent Beneficiary relationships that have ended: *

Speaker - Enter the Name of Ineligible Company *

Speaker - Disease state *

Have any of the Speaker relationships ended? *

Yes

No

Please indicate the Speaker relationships that have ended: *

**All of the relevant financial relationships listed for these individuals will be mitigated.

Section 3: Statement of Understanding

I have secured necessary permission(s) or copyright clearance(s) for any data, illustrations, photographs or any other content requiring permission for use in this educational context. *

Yes

No

N/A - I am a planner or reviewer

I understand that it is my responsibility to disclose to the audience when my discussion includes non-FDA approved indications or dosing recommendations. *

Yes

No

N/A - I am a planner or reviewer

I attest that the above information is correct as of this date of submission. *

First and Last Name

Date *