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.

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.

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. *

Presentation Title

Full Name: *

Work Phone:

Other Telephone:

Work Email:

Affiliation

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

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below).

Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies, please visit accme.org/standards.

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

I have read and understand the ineligible company definition above. *

Yes

	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
1	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
2	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
3	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
4	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
5	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
6	Enter the Name of the Ineligible Company	Enter the Nature of Financial Relationship - Examples include employee, researcher, consultant, advisor, speaker, independent contractor ( including contracted research), royalties or patient beneficiary, executive role and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution received the research grant and manages the funds.	Has the Relationship Ended? Enter Yes or No - If the relationship existed during the last 24 months, but has now ended, please enter no in the box in this column. This will help the education staff determine if any mitigation steps need to be taken.

Please upload a document containing additional relationships if more space is needed.

In the past 24 months, I have NOT had ANY financial relationships with any ineligible companies. *

I have not

Financial Relationship Attestation *

I attest that the above information is correct as of this date of submission.

I attest that all financial relationships as disclosed are up to date.

I attest that clinical recommendations are evidence-based and free of commercial bias (e.g., peer- reviewed literature, adhering to evidence-based practice guidelines)

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 *