Disclosure Form

Disclosure Information

Information provided will be made available to activity participants per CPME standards. Please contact Rich Dubin if you have any questions while completing this form 518-221-4042 or richdubin@gmail.com.

Participants of an accredited activity are required to disclose all personal financial relationships, over the previous 24 months, with ineligible companies. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest), or other financial benefits; and has the opportunity to affect activity content relevant to products or services of that ineligible company. Research grants from ineligible companies are financial relationships that should be disclosed, even if the funds go to the researcher’s institution and not to the individual researcher.

An ineligible company is an entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

The intent of this policy is to allow for a determination to be made as to whether any relationship may constitute a real or apparent conflict of interest. Disclosure that an activity participant has no relevant financial relationships must also be provided to the learners.

Name(Required)

First Last

Credentials

Email(Required)

Phone(Required)

Facility/Institution

What is your role in this activity?

Those who are assuming a dual role as a Planner / Speaker, are required to submit a separate disclosure for each role.

Other, Please Specify

Presentation Title(s) / Topic(s)

Disclosure of All Financial Relationships

List the names of ineligible companies producing, marketing, selling, re-selling, or distributing health care goods or services consumed by, or used on, patients; and the type of financial relationship you have at present, or had within the past 24 months with those entities.

Financial Relationship

I have not had a financial relationship with an ineligible company in the past 24 months.

I have had a financial relationship with an ineligible company in the past 24 months.

Disclosure 1

Ineligible Company

Type of Relationship

Speaker's bureau, research grant, retained consultant, stockholder, etc.

Does this relationship constitute a real or apparent conflict of interest based on your participation in the activity?

Resolution of Conflict of Interest

Select one or more of the following to resolve a potential conflict of interest.

My disclosed relationship will not influence my ability to give a fair and unbiased presentation based on clinical evidence

Review and change my presentation to eliminate relevance to health care goods or services of my disclosed relationship

Select a co-presenter to control the segment of the presentation in question

Change my role to one that precludes me from making clinical recommendations

Support my presentation and clinical recommendations with the "best available evidence" from the medical literature

Refrain from recommending health care goods or services produced by the ineligible with which I have a disclosed relationship

Divest myself of my relationship with the ineligible company

Recommend an alternative presenter for this topic for the planning committee's consideration

Other

Other, Please Specify

Add Another Disclosure

Yes

Disclosure 2