Beth Israel Medical Center and

St. Luke’s and Roosevelt Hospitals

FINANCIAL RELATIONSHIPS DISCLOSURE FORM FOR INSTRUCTORS, PLANNERS AND MANAGERS OF CONTINUING MEDICAL EDUCATION ACTIVITIES

Beth Israel Medical Center (BIMC) and St. Luke’s and Roosevelt Hospitals (SLRCH) expects that CME activities be free of commercial influence, that all research reported is scientifically valid, that all information reported is accurate, and that all recommendations are made with the interest of the public placed above any individual interests. As such, the Office of Continuing Medical Education requires that any pertinent financial relationships with commercial interests (in the preceding 12 months) be disclosed so that any conflict(s) of interest may be identified and resolved prior to the start of the CME activity.

CME ACTIVITY/DATE: ______

INSTITUTION/DEPARTMENT: ______

NAME (PLEASE PRINT OR TYPE): ______

ADDRESS: ______

E-MAIL: ______

Please indicate your role in this CME activity: Presenter Course Director Moderator

Planning Committee Member Author Peer Reviewer

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation(s).

I do not have any relevant financial relationships with any commercial interests. [If this box is checked, please sign

below and submit this form, otherwise proceed to Page 2)

______

I have financial relationship(s) with commercial interest(s) as outlined below.

INSTRUCTIONS FOR DISCLOSING FINANCIAL RELATIONSHIPS WITH COMMERCIAL INTERESTS:

First, list the name of the proprietary entities producing healthcare goods and services, with the exemption of non-profit or government organizations and non-healthcare related companies, with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For CME purposes, BIMC and SLRHC considers the relevant financial relationship(s) of your spouse/partner that you are aware of to be yours.

Second, describe what you or your spouse/partner received [Examples: salary, royalty, intellectual property rights, patent rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interests, excluding diversified mutual funds), etc.]

Third, describe the role of you or your spouse/partner [Examples: employment, management position, independent contractor (including contracted researcher), consulting, teaching and speaking, membership on advisory committees or review panels, board membership, etc.]

Fourth, if the financial relationship is linked to a specific product, please write down its generic name

Fifth, indicate whether the total amount received over the past 12 months was less than $5,000.

Sixth, return form by the deadline outlined in the faculty letter that accompanied this form.

Commercial Interest / What Was Received? / What Was
Your Role? / Generic Name of Specific Product
(if applicable)? / Total amount less than $5,000?
Example: Company “X” / Honoraria / Speaker / Ibuprofen / X Yes
Yes No
Yes No
Yes No
Yes No

I represent that the foregoing information is complete and truthful.

Signature of Reporting Individual Date of Submission


RESOLUTION OF CONFLICTS

Presenter/Authors

I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature.

I will refrain from making recommendations, regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and/or research findings.

I will recommend an alternative presenter for this topic for the planning committee’s consideration.

I will submit my talk in advance to allow for adequate peer review.

I will or have divested myself of this financial relationship.

Planners

To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.

I will recuse myself from planning activity content in which I have a conflict of interest.

GLOSSARY OF TERMS

Commercial Interest

The ACCME and the Office of Continuing Medical Education at BIMC and SLRHC define a commercial interest as any proprietary entity producing healthcare goods or services, with the exemption of non-profit and government organizations and non-healthcare related companies.

Commercial Support

The ACCME and the Office of Continuing Medical Education at BIMC and SLRHC define commercial support as financial or in-kind contributions given by a commercial interest, which are used to pay all or part of the costs of a CME activity.

Financial Relationships

Financial relationships are those relationships in which the individual benefits by receiving a salary, 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 advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. Contracted research includes research funding where the institution gets the grant and also manages the funds. Importantly, ACCME and the Office of Continuing Medical Education at BIMC and SLRHC consider relationships of the person involved in the CME to include financial relationships of a spouse or partner.

Conflict of Interest

The ACCME and the Office of Continuing Medical Education at BIMC and SLRHC consider financial relationships to create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest. The ACCME considers “content of CME about the products or services of that commercial interest” to include content about specific agents and/or devices, but not necessarily about the class of agents and/or devices, and not necessarily content about the whole disease class in which those agents and/or devices are used.

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