Agreement Concerning Support from a Commercial Company

AGREEMENT CONCERNING SUPPORT FROM A COMMERCIAL COMPANY

FOR A CONTINUING MEDICAL EDUCATION ACTIVITY OF THE

UNIVERSITY OF NORTH DAKOTASCHOOL OF MEDICINE AND HEALTH SCIENCES

PROGRAM: / PROGRAM DATE:
RESPONSIBLE ORGANIZATION/DEPT:
UNDSchool of Medicine & Health Sciences
Continuing Medical Education & Outreach / PROGRAM LOCATION:
CONTACT / RESPONSIBLE INDIVIDUAL:
Mary Johnson / Gwen W. Halaas, M.D., M.B.A. / PHONE:
701-777-3201
ADDRESS:
Continuing Medical Education & Outreach
School of Medicine Room 1116
501 North Columbia Road Stop 9037
Grand Forks, ND58202-9037 / FAX:
701-777-4261
COMPANY NAME:
REPRESENTATIVE: / PHONE:
ADDRESS: / FAX:
EMAIL:

SUPPORTThe above named company is providing the following support to the designated CME activity:

PROVIDED Financial support paid to the MedicalSchool in the amount of

$ This support is for:

The general expenses of the CME Activity.

 Specific expenses of the CME activity (e.g., speaker honoraria/lunch):

1.

2.

 Other support for the CME activity (e.g., use of company's equipment):

1.

2.

AUTHORIZED The UNDSMHS authorized the company to perform the following activities in conjunction

with the UNDSMHS CME activity.

ACTIVITIES No activity

 Activity (e.g., commercial exhibit):

1.

2.

(CME activity development and production are not delegated to commercial supporters.)

Agreement (Con’t.)

GENERALThe support is provided and accepted in accordance with the Accreditation Council for Continuing Medical Education Standards for Commercial Support of CME. Some of the Standards include:

(1)The University of North Dakota School of Medicine and Health Sciences (UNDSMHS) controls the content and production of the CME activity.

(2)The UNDSMHS assures the presentation of balanced, objective information.

(3)Unlabeled uses of products must be disclosed.

(4)If exhibits are present they will not interfere with the educational activity.

(5)All commercial support funds should be made payable to the UNDSMHS.

(6)Commercial support will be acknowledged to participants.

(7)The sponsoring UNDSMHS unit and the CME activity faculty will disclose significant relationships with companies providing commercial support or whose products will be discussed.

(8)Social activities will be modest and will not take precedence over educational activities.

SIGNATURES

Company Representative Date UNDSMHS Activity Director Date

Three Copies: One each to the Company Representative, the UNDSMHS - CMEO Activity Director, and the CMEO Activity File.