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Displaying 13 of 17 respondents
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1. First Name:
2. Last name; Degree(s)(i.e. M.D., PhD, RN, etc. if applicable)
3. Institution:
4. CME Activity Name:
5. Date of CME Activity:
6. What role do you have in this CME activity?
7. On behalf of yourself and your spouse/partner, please select one of the choices below:
I/We do have financial relationships to disclose with commercial entities producing, marketing, re-selling, or distributing health care goods or services.
1. Name of Commercial Entity:
2. Please indicate what the relationship is with the commercial entity listed above:
3. Name of Commercial Entity:
No Response
4. Please indicate what the relationship is with the commercial entity listed above:
No Response
5. Name of Commercial Entity:
No Response
6. Please indicate what the relationship is with the commercial entity listed above:
No Response
7. Name of Commercial Entity:
No Response
8. Please indicate what the relationship is with the commercial entity listed above:
No Response
1. Please indicate your understanding of and willingness to comply with each statement below.
They are based on requirements of the Accreditation Council for Continuing Medical Education
(ACCME). If you have any questions regarding your ability to comply, please contact the course
director as soon as possible.

Agree Disagree
I have disclosed all relevant financial relationships with commercial entities producing, marketing, re- selling, or distributing health care goods or services consumed by, or used on, patients.
The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a Content for this activity, including any presentation of therapeutic options, will be well balanced, unbiased, and to the extent possible, evidence-based. Opinions that are not supported by evidence, or are supported by limited or preliminary evidence will be so identified.
I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with the course director.
I understand that the course director may need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.
2. Additional Attestations
Agree Disagree N/A
If I am presenting at a live event, I understand that a CME monitor may be attending the event to ensure that my presentation is educational, and not promotional, in nature. If I am providing recommendations involving clinical medicine, they 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 I refer to, report, or use in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.
For any drug/product discussed, the data must be objectively selected and presented, both favorable and unfavorable information about the drug/product must be fairly presented, and I will include information about reasonable alternative treatment options. Where there is a suggestion of superiority of one drug/product over another, this suggestion needs to be supported by evidence-based data.
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.
If I am discussing any drug/product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA.
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 with this activity.
If I am presenting research funded by a commercial company, I will identify it and the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.
3. Full name (this is your electronic signature and binding obligation)
4. Date (month/date/year)


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