Continuing Education (CE)

The Accreditation Council for Continuing Medical Education (ACCME) requires Morehouse School of Medicine to identify and resolve conflicts of interest for all individuals responsible for the development, management, presentation, and/or evaluation of a CE activity. In order to fulfill this requirement, MSM can only approve a CE activity when all involved individuals have completed the following disclosure form.

Purpose: To assure fair and unbiased presentation of valuable educational materials and to comply with the ACCME Standards for Commercial Support.

Who: Planning committee members, speakers, presenters, moderators, Course Directors, authors, etc.

How Often: Annually or within 30 days of terminating or acquiring a new relevant financial relationship.

Instructions: Read and complete each section of this form, ensuring that appropriate check boxes are selected and that signature and date are affixed where indicated. Please fill out the form completely prior to clicking the submit button.

Activity title *

Please identify your role in this activity. *

Enter the Title of Activity (Do not enter the title of your presentation) *

Presentation Title

Full Name: *

Work Address *

Work Phone:

Fax:

Other Telephone:

Work Email:

Affiliation

Education: (Include highest degree education and pertinent education to activity content)

	Degree Awarded	Institution	Major Area of Study	Year of Degree
1	Degree Awarded	Institution	Major Area of Study	Year of Degree
2	Degree Awarded	Institution	Major Area of Study	Year of Degree
3	Degree Awarded	Institution	Major Area of Study	Year of Degree
4	Degree Awarded	Institution	Major Area of Study	Year of Degree

Briefly describe expertise and years of training specific to the educational activity. Attach a copy of your CV/Resume by clicking on Add Attachment Button. (If the description of expertise does not provide adequate information, the CE Planner may request additional documentation.) *

Add Attachment

Policies and Procedures

Policies & Procedures *

I agree to abide by the Morehouse School of Medicine's Policies and Procedures.

Fair Balance, Independent Content Validation, Level of Evidence

Content Validation Statement: All recommendations involving clinical medicine in a CE activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contra-indications in the care of patients. All scientific research referred to, reported or used in CE in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. *

I understand that presentation slides/abstract/monograph, etc. (CE activity materials) may be peer reviewed and edited accordingly prior to the CE activity occurring (or being released) and evaluated by participants for fair balance and to validate content.

I attest that any and all clinical recommendations that I make for patient care as part of my planning and/or CE activity materials will be based on the best available evidence, that a balanced view of therapeutic options will be given, and the content will be in accordance with Content Validation Statement. I will also provide the level of evidence for said recommendations in the CE activity materials.

Off-Label Uses and Limitations of Data

Off-Label Uses and Limitations of Data *

I agree to make meaningful disclosure to the attendees of this CE activity when products or procedures I discuss at the above CE activity are off-label, unlabeled, experimental, and/or investigational (not FDA approved), and any limitations on the information that I present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.

HIPAA, Copyright Permission(s), and Opportunity for Debate

HIPAA, Copyright Permission(s), and Opportunity for Debate *

I attest that my CE activity materials will be HIPAA compliant (i.e., I will use de-identified patient information when possible).

I agree to obtain the necessary copyright permission(s) if any portion of my CE activity materials that I prepare is not my original work or for which I do not hold the copyright

I agree to provide meaningful opportunity for questioning or scientific debate (live presentation).

CE Content Information

General Content of CE Activities in which you will/plan to participate (example: Genitourinary Cancers and other topics in Urology):

Topic *

Disclosure of All Financial Relationships

All questions below are based on the ACCME definition of Commercial Interest.

Please review the definition and respond to each question below.

Commercial Interest Definition (ACCME Defined)

I have read and understand the commercial interest definition above *

Yes

No

2. Do you or your spouse have or have either of you had a financial relationship within the past 24 months with the following:

a. Any proprietary entities producing health care goods or services (commercial interests) with the exemption of non-profit or government organizations and non-health care related companies. *

Yes

No

b. Any proprietary entities that market, re-sell or distribute healthcare goods? *

Yes

No

Do you have a relationship to disclose? Commercial Interest definition (ACCME Defined) * 🛈

Yes	No, I have nothing to disclose

A. List the names of proprietary entities producing health care goods or services (commercial interests) with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a financial relationship within the past 12 months. For this purpose the financial relationships of your spouse or partner that you are aware of to be yours. (note: if you do not have any financial relationships to disclose, please skip to D).

B. Delineate what you or your spouse/partner received (ex: salary, honorarium etc). MSM does NOT want to know how much you or your spouse/partner received.

C. Delineate you or your spouse/partner's role.

Nature of Financial Relationships (include all that apply)

If yes, please provide financial relationship information below.

	Commercial Interest (Ex. ABC Pharma)	What was received? (Ex. Honorarium)	For what role? (Ex. Speaker)
1	Commercial Interest (Ex. ABC Pharma)	What was received? (Ex. Honorarium)	For what role? (Ex. Speaker)
2	Commercial Interest (Ex. ABC Pharma)	What was received? (Ex. Honorarium)	For what role? (Ex. Speaker)
3	Commercial Interest (Ex. ABC Pharma)	What was received? (Ex. Honorarium)	For what role? (Ex. Speaker)

Complete this section only if want CME credit for developing your presentation

1. Are you seeking CME credit for the development of this presentation?

Yes

No -(Go to Signature and Submit)

2. Have you received CME credit for the development of this activity in the past?

Yes

No

If you selected Yes, have you modified the presentation since receiving CME credit *

Yes

*No- (Go to Signature and Submit)

3. Complete to receive CME credit for presentation development

	What is the length of the final presentation?	How much time was spent developing the presentation?
Hours	What is the length of the final presentation?	How much time was spent developing the presentation?

*ACCME guidelines only allows a one time credit for presentation development.

Entering your name in the signature text box below constitutes an electronic signature.

Signature *

Date Submitted * +

Please respond: Was this form completed by someone other than the person named on the first page of this form? *

Yes

No

If yes, please provide name of person competing form *

Email Address *