Disclosure / Content Validation Form

FSPHP 2022 Annual Meeting _ April 26-28, 2022

Disclosure Information

Information provided will be made available to activity participants per ACCME standards. Please contact the CineMed Continuing Education Department if you have any questions while completing this form 203-263-0006 x112

Participants of an accredited activity are required to disclose all personal financial relationships, over the previous 24 months, with ineligible companies. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest), or other financial benefits; and has the opportunity to affect activity content relevant to products or services of that ineligible company. Research grants from ineligible companies are financial relationships that should be disclosed, even if the funds go to the researcher’s institution and not to the individual researcher.

An ineligible company is an entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

The intent of this policy is to allow for a determination to be made as to whether any relationship may constitute a real or apparent conflict of interest. Disclosure that an activity participant has no relevant financial relationships must also be provided to the learners.


Those who are assuming a dual role as a Planner / Speaker, are required to submit a separate disclosure for each role.
Enter N/A if not presenting.
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Disclosure of All Financial Relationships

List the names of ineligible companies producing, marketing, selling, re-selling, or distributing health care goods or services consumed by, or used on, patients; and the type of financial relationship you have at present, or had within the past 24 months with those entities.

Fair Balance, Independent Content Validation and Level of Evidence

Content Validation: All recommendations involving clinical medicine in a CME/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 CME/CE in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. Please contact CineMed's Continuing Education Department if you do not feel your presentation(s) can meet these standards (203-263-0006 x112).

Off-Label Uses and Limitations of Data

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