NJAFP Disclosure Form – Support Site

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Disclosure Form, 2020 FamMed Forum - Step 1 of 6

Name *

First

Last

Email *

Email

Confirm Email

Phone

CME Activity Name: *

Program/Presentation Title (If you are not a presenter, please enter N/A) *

Role(s): Check All that Apply *

Planner/Core Faculty
Reviewer
Course Director
Moderator/Teacher/Author
Other

Other (Please Describe)

Please list any non-financial conflict of interest. Examples would be Speaking/teaching, member of an association, membership on advisory or review panels, chairing a related voluntary committee, board member etc. (If you have no non-financial conflicts of interest, please answer N/A.) *

CRITERIA FOR DISCLOSURE OF FINANCIAL RELATIONSHIPS WITH COMMERCIAL INTEREST

1. Anyone who can affect the content of an accredited educational activity is required to disclose financial relationships they may have with commercial interests (i.e., any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients).

2. You are to disclose financial relationships in any amount that has been received over the past 12 months ONLY.

3. Financial relationships with government agencies (e.g., the NIH) and organizations that do not fit the above definition of a commercial interest do not have to be disclosed.

4. Honoraria or consulting funds received from a CME/CE provider, even though those funds may have been provided to that CME/CE provider through an educational grant from a commercial interest, do not have to be disclosed.

5. If you are a principal investigator for a drug study, you must report that research relationship below under "Contracted Research" even if those funds came to an institution.

6. If your spouse or life partner has a relevant financial relationship with an applicable commercial interest (e.g., is employed as the VP-Marketing), or provides marketing advice to an applicable commercial interest as a consultant, you must include that disclosure in the table below.

7. In accordance with requirements, failure to provide disclosure information in a timely manner will result in the disqualification of the potential planner, course director, moderator, faculty, presenter, author or reviewer from this activity.

Within the past 12 months, have you and/or your spouse/ life partner received support from, or had a relationship with, a commercial interest? *

No
Yes, within the past 12 months from today’s date, I or my spouse/life partner have/has had a relevant financial relationship with a commercial interest as listed below.

Salary (employed relationship)

Name of Applicable Commercial Interest

Royalty and/or Receipt of Intellectual Property Rights/Patent Holder

Name of Applicable Commercial Interest

Consulting Fee

Name of Applicable Commercial Interest

Speakers Bureau

Name of Applicable Commercial Interest

Fees for Non-CME/CE Services Received Directly from a Commercial Interest or its Agent

Name of Applicable Commercial Interest

Contracted Research

Only include research funds received directly from industry; grants to your institution are NOT reportable. If you are a principal investigator, you must report a financial relationship even if those funds came to the institution for which you work.

Ownership Interest

Include stocks, stock options, or other ownership interest excluding diversified mutual funds

Other

Please describe

If you reported relationships in the questions above, will any of these relationships impact your ability to present an unbiased presentation? *

Yes
No

Please explain *

Do you intend to reference unlabeled/unapproved uses of drugs or products in the educational activity? *

Yes
No

Names of drugs or products you will reference: *

PART III: Attestation of CME Value Statements

Please indicate your understanding of and willingness to comply with each statement below. If any statements do not apply to your participation in this activity, select "N/A." If you require clarification of these statements or have questions regarding your ability to comply, please contact the CME/CE Office immediately.

I have disclosed all relevant financial relationships and I will disclose this information to learners *

Agree
Disagree

The content and/or presentation I am involved in will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be balanced, evidence-based and commercially unbiased. *

Agree
Disagree
N/A

I have not and will not accept any honoraria, additional payments or reimbursements directly from a commercial interest for my participation in this activity. *

Agree
Disagree
N/A

I understand that the CME/CE provider may need to review my presentation and/or content prior to the activity, and I will provide content and resources in advance as requested *

Agree
Disagree
N/A

If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All reference to scientific research will conform to the generally accepted standard of experimental design, data collection and analysis. *

Agree
Disagree
N/A

If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company. *

Agree
Disagree
N/A

If I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA. *

Agree
Disagree
N/A

If I am presenting research funded by a commercial interest, the information presented will be based on generally accepted scientific principals and methods and will not promote the commercial interest of the funding company. *

Agree
Disagree
N/A

NJAFP plans to record all sessions so that participants who were not able to attend the live session can still access the content asynchronously. Please indicate your permission to record your session and make it available only to registered attendees of the conference. *

Yes, I give my permission to record my presentation for access by registered attendees.
I agree to stream the live event, but not to have my session recorded.

Typing my name in the space above indicates that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided on page 1 of this form will be shared with learners prior to their engagement in this CME activity. *

Date *

Email