Financial Relationship Disclosure for CME Presenters, Panelists, Moderators Name(Required) First Last Role(Required)(e.g., Planning Committee Member, CME Committee Chair, Activity Director, Speaker,Moderator, Panelist, etc.)Activity or Conference Title(Required)Activity Date OR Planning Year for which Disclosure is Valid(Required)The purpose of this form is to identify and resolve all potential conflicts of interests that arise from financial relationships with ineligible companies. The ACCME defines an ineligible company as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME considers financial relationships a conflict of interest when individuals have both a financial relationship with an ineligible company and the opportunity to affect the content of CME.Check one of the boxes below(Required) I have no relevant financial relationships with any entity producing, marketing, re-selling, or distributinghealthcare goods or services consumed by, or used on, patients. I disclose the following financial relationship(s) with entities producing, marketing, re-selling, or distributinghealth care goods or services consumed by, or used on, patients: Please indicate any financial relationships with ineligible companies you have had within the last 24 months.(Required)CompanyType of Relationship*Service/Product/ Clinical AreaRelationship has ended (yes: month/year) or no Add Remove*Type of relationship may include independent contractor, consultant, advisory committee, board membership, expertpanel, research or other grant recipient, paid speaker or teacher, membership on advisory committees or review panels,intellectual property/patent holder, ownership interest (product royalty/licensing fees, owning stocks, shares, etc) or anyother financial relationship. Note: The ACCME does not consider providers of clinical services directly to patients to becommercial interests unless the provider is owned or controlled by an ineligible company.By checking this box, I attest that this information is correct as of the date of submission. I affirm that I will notify the UMA Foundation if my financial relationships change and will submit a new disclosure form for activities in which I have control of content.(Required) I agree Electronic Signature(Required) First Last Date(Required) MM slash DD slash YYYY Please indicate your understanding of and willingness to comply with each statement below. If you have any questions regarding your ability to comply, please contact the activity coordinator as soon as possible.The content and/or presentation of the information with which I am involved will promote quality orimprovements in healthcare and will not promote a specific proprietary business interest of a commercialinterest. Content for this activity, including any presentation of therapeutic options, will be balanced, evidence-based, and unbiased.(Required) Agree Disagree I understand that the UMA Foundation and/or its educational partner may need to review my presentationand/or content prior to the activity and I will provide educational content and resources in advance as requested.(Required) Agree Disagree If I am providing recommendations involving clinical medicine, the recommendations will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection, and analysis.(Required) Agree Disagree If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available and not just trade names from any single company.(Required) Agree Disagree N/A If I am discussing any product that is off label, I will disclose that the use or indication in question is not currently approved by the FDA for labeling or advertising.(Required) Agree Disagree N/A If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way in my presentation.(Required) Agree Disagree N/A If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods and will not promote the commercial interest of the funding company.(Required) Agree Disagree N/A Electronic Signature(Required) First Last
