CONTINUING MEDICAL EDUCATION

DISCLOSURE OF FINANCIAL INTERESTS

THE UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE

DISCLOSURE OF FINANCIAL INTERESTS OR RELATIONSHIPS

It is the policy of the University of Illinois College of Medicine (UI-COM) that any individual in control of the content of an activity (e.g. planning committee member, speaker) designated for American Medical Association Physicians Recognition Award (PRA) Category 1 credit™ must disclose any financial interest or other relationship (i.e. grants, speakers bureau, research support, consultant, full-time/part-time employment, honoraria, royalty, stock) which that individual, or his/her immediate family members have OR have had within the previous calendar year with the manufacturer(s) of any commercial product(s) that may be discussed in the educational presentation.

UI-COM does not imply that such financial interests or relationships are inherently improper or that such interests or relationships would prevent the individual from participating in the CME activity. However, failure to disclose or false disclosure will require UI-COM to identify a replacement for you. Conflicts of interest, as determined by the activity director and department head, must be resolved prior to the activity. Choose one of the two statements below and sign the form just once.

UNLABELED USE OF PRODUCTS – Speakers must disclose that the product is not labeled for the use under discussion or that the product is still investigational.

Title of CME Activity
Activity
Location / Activity Date

I agree to follow the UI-COM and ACCME policies outlined above, and:

I, the undersigned, declare that I or my immediate family does not have a financial interest or other relationship with any manufacturer(s) of any commercial products or services which may be discussed at the conference.

I, the undersigned, declare that I or my immediate family have a financial interest or other relationship with a manufacturer(s) of a commercial products or services which may be discussed at the conference.

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