UUCME Speaker / Planner Disclosure Form

Transcription

1 As a provider approved by the Accreditation Council for Continuing Medical Education (ACCME), The University of Utah School of Medicine Continuing Medical Education Office (UUCME) requires disclosure of the existence of relevant financial relationships with commercial interests from any individual in a position to control the content of a CME activity. Individuals who refuse to disclose relevant financial relationships or refuse to attest to the statements at the end of this form will be disqualified from all aspects of associated CME activities. Everyone in a position to control the content of a CME activity must disclose to UUCME and to the learners; all his/her relevant financial relationships and all potential conflicts must be resolved PRIOR to the activity. * 1. Your Name * 2. CME Activity Title 3. Date of Activity Date MM/DD/YYYY 4. Academic Year 5. Title of your presentation * 6. What is your role in this activity? (check all that apply) Planner Speaker Moderator 1

2 * 7. Do you or your spouse/partner have or expect to have within the 12 months leading up to your presentation(s) or control of content for this activity, any financial relationship or gift-in-kind with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients (a commercial interest) that is relevant to the subject matter of the presentation? No Yes ALERT! Funded research is a financial relationship you should consider. If you are on a research grant from a pharmaceutical or device company or its parent company (or any entity that fits the commercial interest definition below) and the content of the educational activity relates to any business line of that company, you should answer "yes" to the above question. If the grant is from the NIH, CDC, VA or other governmental entity, this is NOT considered a commercial interest and you should answer "no" above. DEFINITIONS Commercial Interest A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. Financial relationships Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership or advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. We consider relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. Relevant financial relationships The ACCME defines "relevant financial relationships" as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. Any relationship that is related to the content of your presentation is considered relevant. The ACCME has not set a minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. Conflict of Interest Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship. Providers must resolve conflicts of interest prior the educational activity. A conflict of interest depends on the situation, and not on the character or actions of the individual. 2

3 * 8. Since you answered YES to a relevant financial interest, please complete the chart below to list all relevant financial relationship(s) or gift(s)-in-kind you or your spouse/partner has or expects to have. Include both the name of the company and the type of financial relationships (see below for typical types of relationships). Typical financial relationships include, but are not limited to: Employment/Salary Grant/Research funding (PI or named in the grant, including contracted research) Paid member of committees, panels or boards Ownership interest (equity, stock, excludes mutual funds) Royalty/IP Speakers' Bureau Consultant/Advisor Honorarium (include reason received) Other (please explain) 9. Do you have more relevant financial relationships to disclose? No Yes If you prefer to an existing document of your financial relationships to accompany your disclosure, please send to CME.Office@hsc.utah.edu. Please be sure to include you name and the CME-activity you are working with in your . 3

4 10. Additional relevant financial relationships, if needed. Include both the name of the company and the type of financial relationships (see typical types of relationships above). 4

5 * 11. The ACCME requires that any conflict be resolved to ensure that CME content is scientifically balanced and free of commercial bias. Please suggest methods that you woud like to use to resolve your conflict(s). (Check all that apply) I will refrain from making recommendations regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and/or research findings. I will support presentation and clinical recommendations by referencing the "best available evidence" in the medical literature and by identifying the conclusions that the evidence supports. I will refrain from making any clinical care recommendations. 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. I will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. I will present well-balanced, evidence-based, and unbiased content, including any therapeutic options. My role will be regulated as to what is said (Cannot say nor do this...). My presentation will be peer reviewed using UUCME's Content Review Form to ensure no bias and that the content is valid Other (please specify) Your suggestions will be reviewed by a content expert who does not have conflicts. The CME activity director will let you know if these methods are adequate and appropriate given your unique presentation and relationships. If they are not adequate, another method will be proposed. All conflicts must be resolved prior to the CME activity. 5

6 * 12. Attestation If my or my spouse/partner's relevant financial relationships change from what I have reported prior to my participation in this CME activity, I will alert UUCME. My recommendations involving clinical medicine in this CME activity 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 CME in support or justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis. By typing my name or signing below, I hereby attest that the information I provided is legitimate and true to the best of my knowledge. 13. Date completed Date MM/DD/YYYY Once completed, return form to UUCME (CME.Office@hsc.utah.edu) or call (801) with any questions. Thank you! 6