Conflict of Interest Reporting Form

AXIS Medical Education

CONFLICT OF INTEREST REPORTING FORM

To comply with the Criteria and Standards of Joint Accreditation, AXIS Medical Education, Inc (AXIS) requires all faculty, presenters, speakers, authors, reviewers, planners, managers, staff, and freelancers (non-faculty) who are in a position to control content to disclose all relevant financial relationships with a commercial interest (personal and/or for his/her spouse/partner) using this document on an annual basis. A conflict of interest (COI) exists when individuals have both a financial relationship with a commercial interest and the opportunity to affect the continuing education content of the product or services of that commercial interest. The Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) each hold the provider of continuing education responsible for collecting information from its planners and managers of CE content and resolving those conflicts prior to the commencement of the CE activity. The intent of the COI resolution process is to ensure that provider, faculty, and planner financial relationships with commercial interests and resultant loyalties do not supersede the public interest in the design and delivery of CME/CE activities for the profession.

Criteria for Disclosure of Conflicts of Interest

Faculty, authors planners, managers and reviewers who affect the content of a CE activity are required to disclose to AXIS financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this certified activity over the previous 12 months ONLY.A commercial interest is defined by the ACCME, ACPE, and ANCC as any entity producing, marketing, re-selling, or distributing healthcare goods or services consumed by, or used on, patients. Relationships with governmental agencies (eg, the NIH) do not have to be disclosed.

Name of CME/CE Activity:

Name of Reporting Individual:

Email address:

I am a/an: Chair/Faculty/Author Planner/ManagerReviewer

Type of Financial Relationship
WITHIN THE PREVIOUS 12 MONTHS ONLY / Indicate Applicable Manufacturer(s)/Company
WITHIN THE PREVIOUS 12 MONTHS ONLY
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: / Self Spouse
Serve(d) as a speaker or a member of a speakers bureau for: / Self Spouse
Received research grant from: / Self Spouse
Have a 5% or greater equity interest in: / Self Spouse
Received income in any amount from: / Self Spouse
Other (please specify):
Contracted Research[1] / Self Spouse
Ownership Interest (stocks, stock options, or other ownership interest, excluding diversified mutual funds) / Self Spouse
Other / Self Spouse

I have no real or apparent financial relationships to report.

Signature of Reporting Individual: Date of Submission:

[1]Only include research funds received directly from industry; grants to your institution are reportable only when you’re the person or named investigator on the grant.