2020 Conference CME Disclosure Form- Presenter

The University of Massachusetts Medical School Office of Continuing Medical Education ensures balance, independence, objectivity and scientific rigor to provide content that is evidence based and free of commercial bias as required by the ACCME Standards for Commercial Support.  CME activities promote improvements in health care and not proprietary interests of a commercial interest.  Anyone engaged in content development, planning, or presentation of the activity must complete this form.  An individual who does not disclose or who refuses to disclose is disqualified from participating in the CME activity.  Complete disclosure must be provided to learners prior to the activity.             

Disclosure Form Guideline

The Faculty Disclosure Form must be completed by presenters, course director(s), moderators, planning committee members and any other person(s) participating in or planning activities or conferences. If there is any change in your disclosure status during a 12-month period, a revised Disclosure Form must be completed. Please read the following information regarding relevant financial relationships and complete the disclosure form. When you have filled in all the appropriate fields, sign and date it, and return the form to the course coordinator.

Relevant Financial Relationships

All approved CME activities must be free of the control of commercial interests, If you participate in the planning, design, implementation, presentation, or evaluation of an activity, you must disclose all relevant financial relationships with any commercial interest. A “commercial interest” is any entity producing, marketing, re-selling, or distributing health care goods or service consumed by, or used on, patients (ACCME Standard for Commercial SupportSM: Standards to Ensure the Independence of CME Activities (“SCS”).

A financial relationship is “relevant” if it pertains to the activity’s content matter including any related health care products or services to be discussed or presented. If a conflict of interest exists, it must be resolved prior to the educational activity being delivered. Relevant financial relationships, or the lack of such relationships, must be disclosed to learners prior to the beginning of the educational activity.

Individuals who refuse to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of the curriculum, and cannot have control of, or responsibility for, the development, management, presentation, or evaluation of the activity.

Financial relationships are those relationships in which the individual benefits by receiving a salary, grant, research support, 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 on advisor committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of that person involved in the educational activity to include financial relationships of a spouse or partner.

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. As related to presentations in this CME activity, have you (or your spouse/partner) had a personal financial relationship in the last 12 months with any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients? NO- Skip to DECLARATION and Sign YES- Disclose relevant financial relationships below. Complete Resolution of Conflict of Interest below, which identifies how conflicts will be resolved and sign DECLARATION.(By identifying a conflict of interest, the course director/designee MUST complete the peer review conflict of interest form.)
Any proprietary entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients related to this activity
Salary, royalty, intellectual property rights/patent holder, consulting fees (e.g. advisory board), honoraria (e.g. speakers bureau), contracted research, ownership interest (stock, stock options or other ownership excluding diversified
Conflicts of interest must be resolved prior to the activity. The following mechanisms have been identified to resolve conflicts of interest listed above. Additional information may be requested to resolve conflict of interest. Presenters Authors, Course Directors, Moderators, etc.
• I will uphold academic standards to insure balance, independence, objectivity and scientific rigor in my role in the planning, development or presentation of this CME activity. • I agree to comply with requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). • I will provide verbal disclosure of relevant financial relationships or that no financial relationships exist. • I will inform learners when I discuss or reference unapproved unlabeled uses of therapeutic agents or products.
Signature: