Disclosure / Content Validation Form

OEIS Virtual Meeting _ September 25, 2020

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.

First Name

Last Name

Credentials

Phone

Facility / Institution

What is your role in this activity? Those who are assuming a dual role as a Planner / Speaker, are required to submit a separate disclosure for each role.

Please Specify

Presentation Title(s) / Topic(s) 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.

I have not had a financial relationship with an ineligible company in the past 24 months.

I have had a financial relationship with an ineligible company in the past 24 months.

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).

I understand that my presentation and/or activity materials may be peer reviewed prior to the activity occurring (or being released) for fair balance and to validate content and may be required to be edited accordingly.

I attest that any and all clinical recommendations that I make for patient care as part of my planning and/or 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 ACCME's Content Validation Statement. I will also provide the level of evidence for said recommendations in the activity materials.

Off-Label Uses and Limitations of Data

I agree to make meaningful disclosure to the attendees of this CME/CE activity when products or procedures I discuss 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

I attest that my participation and 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 materials are not my original work or for which I do not hold the copyright.

I agree to provide meaningful opportunity for questions or scientific debate during any live presentation/discussion.

By checking this box, I am approving my electronic signature appearing below and attest that all information provided above is accurate and complete. I also understand that by continuing, I am submitting this electronic document to the CineMed Continuing Education Department, indicating I have read, understood, and agree to abide by the policies and regulations addressed in this form. I further agree to updated this electronic document in the event that any information pertaining to my financial disclosures changes prior to the accredited activity.

Completed By (Name and Credentials)