Conflict of Interest Disclosure Form

Conflict of Interest Disclosure Form


As part of its mission, the University of Manitoba’s Continuing Professional Development (CPD) Medicine Program strives to promote and provide relevant, needs-based educational opportunities to physicians and other health care providers to maintain or produce changes in knowledge, skills, attitudes or behaviors that will enable the optimal provision of patient care. The CPD Medicine Program requires that the content of CME/CPD activities and related materials provide balance, independence, objectivity, and scientific rigor.

The intent of this disclosure is to promote transparency and allow the audience to have complete information with which they can make their own judgments.

  1. Disclosure: Program planners, speakers or authors must sign a conflict of interest disclosure form prior to their involvement with the CME/CPD event. At the start of the activity, all are required to disclose, verbally and with a slide, any existing conflict of interest. The management of actual or perceived conflict of interest will assist learners in assessing the potential for influence in information that is presented.
  1. Objectivity: Planners, speakers or authors are required to prepare fair and balanced presentations which are objective and scientifically rigorous. The presentation slides/abstract/monograph, etc. may be peer-reviewed prior to the event to ensure fair balance and to validate content. Additionally, event may be audited to ensure that it is free of bias.
  1. Content Validation: Speakers and authors will deliver content that is evidence-based and conforms to the generally accepted formats of scientific data presentations. They will not advise or recommend diagnosis or treatment in which the risks outweigh the benefits. Any and all clinical recommendations made relating to patient care will be based on the best available evidence; a balanced view of therapeutic options will be given.
  1. Unlabeled and Unapproved Uses: Presentations that provide information in whole or in part related to non- approved uses for drug products and/or devices must clearly acknowledge the unlabeled indications or the investigative nature of their proposed uses to the audience.
  1. Use of Generic versus Trade Names: Speakers and authors should use generic names in referring to products in their lectures or enduring materials. Presenters will not stress one product over another without scientific evidence for recommendations.
  1. Copyright: Consistent with copyright policy, the speaker or author agrees to obtain the necessary copyright permission(s) if any portion of the materials that he/she prepares is not presenter’s original work and he/she does not hold the copyright.


Program planners, speakers and authors of CME/CPD activities are expected to disclose any significant relationships thatmay pose a conflict with the principles of balance and independence. The following questionnaire will help to evaluate potentialconflicts of interest.

Name of activity
Date of activity

Check any commercial, financial, or research relationships or interests within the past 24 months that you, your spouse, or animmediate member of your family, that could be perceived as a related or apparent conflict of interest in the contract of the subject of the proposed CME/CPD activity.

Type of Affiliation/Financial Support / Name of Commercial Organization / Self / Spouse or immediate family
Consultant /  / 
Speaker Bureau /  / 
Grants/Research Support /  / 
Advisory Board Membership /  / 
Honorarium Recipient /  / 
Stockholder (Not as part of Mutual Fund) /  / 
Trustee/Director /  / 
Other (Describe): /  / 

I have no relationships to disclose

I confirm that all of the above information is a complete and accurate listing of my relevant financial interests.

I agree to abide by the procedures for disclosure and participation described attached to this form.


Please fax this form to 789-3911