Continuing Education Faculty Disclosure Request Form Δ As a prospective planner, reviewer, faculty member, or other position of influence over accredited educational content, we ask for your help in protecting our learning environment from ineligible organization influence. To help us meet these expectations, please use this form to disclose all of your financial relationships with any ACCME-defined ineligible organizations over the past twenty-four (24) months, regardless of whether you view them as relevant to the educational content being planned. Ineligible companies are those 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. 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. After we receive your disclosure information, we will review it to determine whether your financial relationships are relevant to the education. Please note: the identification of relevant financial relationships does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity. Disclosure information is necessary for us to be able to move forward in planning this continuing education activity. We appreciate your diligence and assistance in providing the requested information.I. Disclosure InformationActivity Name:(Required)Name(Required) First name Last name UntitledEmail(Required) What is Your Role:(Required) Planner (e.g. Director, Planning Committee) Faculty (e.g. Speaker, Moderator, Panelist) Reviewer (Content Reviewer) CMDA Staff Joint Provider Staff Other If you selected "other" please specify your role:DefinitionsIneligible Companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Examples of such organizations include: -Advertising, marketing, or communication firms whose clients are ineligible companies -Bio-medical startups that have begun a governmental regulatory approval process -Compounding pharmacies that manufacture proprietary compounds -Device manufacturers or distributors -Diagnostic labs that sell proprietary products -Growers, distributors, manufacturers or sellers of medical foods and dietary supplements -Manufacturers of health-related wearable products -Pharmaceutical companies or distributors -Pharmacy benefit managers -Reagent manufacturers or sellers ACCME focuses on financial relationships with ineligible companies during the 24 months prior to the activity. 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. 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; diversified 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. Important note: A biomedical startup is ONLY considered an ineligible company if it has begun a governmental regulatory approval process. Please do not disclose start up companies if they do not fit the definition. -Drugs: The ACCME considers the submission of the Investigational New Drug Application (IND), which must be approved before clinical trials can begin, as the point of entry into the government regulatory approval process. This graphic published on the FDA website shows where in the drug development cycle the IND is submitted. Once a company makes this submission, it would be considered an ineligible company. -Medical devices: When a company initiates a premarket approval (PMA) process submission, as described on the FDA website here, it would then be considered an ineligible company. Please visit the ACCME website for more details: https://accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ceFinancial RelationshipsHave you had any financial relationships with ineligible companies within the last 24 months?(Required)Important note: Please only disclose financial relationships with ineligible companies (those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients). YES: in the past 24 months, I have had financial relationships with ineligible companies NO: companies (If you checked “No”, proceed to Section II) Have you had any financial relationships with ineligible companies within the last 24 months?(Required)Important note: Please only disclose financial relationships with ineligible companies (those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients). YES: in the past 24 months, I have had financial relationships with ineligible companies NO: companies (If you checked “No”, proceed to Section II) Δ As a prospective planner, reviewer, faculty member, or other position of influence over accredited educational content, we ask for your help in protecting our learning environment from ineligible organization influence. To help us meet these expectations, please use this form to disclose all of your financial relationships with any ACCME-defined ineligible organizations over the past twenty-four (24) months, regardless of whether you view them as relevant to the educational content being planned. Ineligible companies are those 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. 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. After we receive your disclosure information, we will review it to determine whether your financial relationships are relevant to the education. Please note: the identification of relevant financial relationships does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity. Disclosure information is necessary for us to be able to move forward in planning this continuing education activity. We appreciate your diligence and assistance in providing the requested information.I. Disclosure InformationActivity Name:(Required)Name(Required) First name Last name UntitledEmail(Required) What is Your Role:(Required) Planner (e.g. Director, Planning Committee) Faculty (e.g. Speaker, Moderator, Panelist) Reviewer (Content Reviewer) CMDA Staff Joint Provider Staff Other If you selected "other" please specify your role:DefinitionsIneligible Companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Examples of such organizations include: -Advertising, marketing, or communication firms whose clients are ineligible companies -Bio-medical startups that have begun a governmental regulatory approval process -Compounding pharmacies that manufacture proprietary compounds -Device manufacturers or distributors -Diagnostic labs that sell proprietary products -Growers, distributors, manufacturers or sellers of medical foods and dietary supplements -Manufacturers of health-related wearable products -Pharmaceutical companies or distributors -Pharmacy benefit managers -Reagent manufacturers or sellers ACCME focuses on financial relationships with ineligible companies during the 24 months prior to the activity. 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. 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; diversified 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. Important note: A biomedical startup is ONLY considered an ineligible company if it has begun a governmental regulatory approval process. Please do not disclose start up companies if they do not fit the definition. -Drugs: The ACCME considers the submission of the Investigational New Drug Application (IND), which must be approved before clinical trials can begin, as the point of entry into the government regulatory approval process. This graphic published on the FDA website shows where in the drug development cycle the IND is submitted. Once a company makes this submission, it would be considered an ineligible company. -Medical devices: When a company initiates a premarket approval (PMA) process submission, as described on the FDA website here, it would then be considered an ineligible company. Please visit the ACCME website for more details: https://accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ceFinancial RelationshipsHave you had any financial relationships with ineligible companies within the last 24 months?(Required)Important note: Please only disclose financial relationships with ineligible companies (those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients). YES: in the past 24 months, I have had financial relationships with ineligible companies NO: companies (If you checked “No”, proceed to Section II) Have you had any financial relationships with ineligible companies within the last 24 months?(Required)Important note: Please only disclose financial relationships with ineligible companies (those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients). YES: in the past 24 months, I have had financial relationships with ineligible companies NO: companies (If you checked “No”, proceed to Section II)
