2021 INMED CME Disclosure Form

Disclosure of Relevant Financial Relationships

By Speakers, Authors, and Planners of Continuing Educational Activities
The intent of this disclosure is to allow the Institute for International Medicine the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its CME activities. All planners and faculty of INMED sponsored activities are expected to disclose to INMED any relevant financial relationships with any commercial interest that produces health care goods or services related to the content of the educational activity or presentation in which they are involved with.

Commercial Interest: any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests.

Conflict of Interest: When an individual’s interests are aligned with those of a commercial interest the interests of the individual are in ‘conflict’ with the interests of the public.

Financial Relationships: are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, or other financial benefit. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research funding where the institution gets the grant and manages the funds and the person is the principal or named investigator on the grant.), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

For full information on ACCME Standards for Commercial Support: Click Here
Your Role: *

Planner Author Presenter/Faculty Moderator Poster Presenter Content Expert Content Reviewer Develop Agenda/Oversee Checklist and/or Sign ins
Full Name *

First Name Last Name
Please provide your credentials *
Place N/A; if no credentials are available
E-mail *
example@example.com
Organization hosting the activity/Joint-Provider: *
If you participate in various activities with multiple joint-providers, please select all that apply.
Please provide name of Organization hosting the activity if not listed above:
Activity Name: *
If you participate in multiple activities you can note ''multiple activities''
Title of Presentation:
Please provide 2-3 learning objectives for your presentation: *
Date of Activity (or date of first activity for the year) *

Month Day Year
Do you (past 24 months) have financial relationships (no minimum threshold) with proprietary entities producing health care goods or services? INMED requests ALL financial relationships as a courtesy in order to allow physicians to complete a single disclosure that can be used for all activities in which we provide accreditation for. Please include ALL financial relationships and not just relevant ones. (hover here for additional information) *

Yes No
I will update INMED of any Commercial Interest Financial Relationships change after completing this form. *

I agree

Open COI = Yes
___________________________________________________________________________

TO ALL SPEAKERS AND PLANNERS WHO DOCUMENT A RELEVANT FINANCIAL RELATIONSHIP WITH ANY COMMERCIAL INTEREST THAT PRODUCES HEALTH CARE GOODS OR SERVICES CONCERNED WITH THE CONTENT OF EDUCATION PRESENTATION IN WHICH THEY ARE INVOLVED.

In an effort to comply with the ACCME requirement to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all CME activities, we are asking that you consider one or more of the following options to assist INMED in its responsibility to ensure appropriate choice of speakers and planners.

All disclosures will be published to attendees prior to the activity.

Please identify commercial interest(s)/organization(s) next to the best description of this/these relationship(s). Please list ALL Commercial Financial Relationship(s) for the past 12 months. (Hover mouse here for additional description) *

	Name of Commercial Interest/Organization
Grant/Research Support (including institution receiving funding for work you do as a PI):
Consultant:
Speaker's Bureau:
Major Stock Shareholder in an ACCME or ANCC/Midwest MSD defined Commercial Interest :
Other Financial/Material Support:

Collapse Presenter/Authors if COI

Collapse COI = Yes

Collapse Planners

Collapse All Presenters/Authors

Consent to Record
Will you allow the Institute for International Medicine to photograph, record, and/or videotape your presentation at the aforementioned continuing education activity? The reproductions of this conference will be used for reviewing the program for compliance with accreditation requirements of the Accreditation Council for Continuing Medical Education and INMED CME policies and procedures, and may be reviewed by medical students, residents, physicians, or other health professionals for educational purposes. *

Yes No N/A
Will you authorize INMED to use the information or other materials there from for such other non- commercial purposes as they deem necessary or proper and agree that neither INMED will be required to pay you any compensation for such agreed-upon uses of the reproduction of the CME activity that is the subject of this release? *

Yes No N/A
Will you release from liability, INMED, and its employees and agents, including any physicians or nurses involved in the development, reproduction or future use of the aforementioned program, provided such use is in compliance with the terms of this release? *

Yes No N/A

Declaration
I will uphold academic standards to insure balance, independence, objectivity, and scientific rigor in my role in the planning, development or presentation of this CE activity as follows:

Presenter/Authors

• Teach to the objectives identified for this activity.

• I will support my presentation and clinical recommendations with the "best available evidence" from the medical literature.

• Present the source and type or level of evidence (i.e., animal study, RCT, meta-analysis, etc.)

• Disclose off-label use(s) of any commercial products, services, or devices being presented.

• Disclose any relevant financial relationships related to (1) the activity’s content and/or (2) the activity’s supporter/s.

• Remove any trade names, or product-group messages from slides, abstracts, or handouts.

• I will submit my talk in advance for adequate peer review.

• I will advise CE Department of any changes to my disclosure prior to my presentation.

Planners

• To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.

• If requested by the CE Department, I will recuse myself from planning activity content in which I have a conflict of interest.

In addition, I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996. (HIPAA) by de-identifying patient information to protect the privacy of the patient.
Items to be de-identified include: 1) Names; 2) All elements of dates (except year) [Birth, admission, discharge, death, etc]; 3) Telephone numbers; 4) Fax numbers; 5) Electronic mail addresses; 6) Social security numbers; 7) Medical record numbers; 8) health plan beneficiary numbers; 9) account numbers; 10) certificate/license numbers; 11) vehicle identifiers and serial numbers, including license plate numbers; 12) device identifiers and serial numbers; 13) web universal resource locators (URLs); 14) Internet Protocol (IP) address numbers; 15) Biometric identifiers, including finger and voice prints; 16) full face photographic images and any comparable images; and 17) any other unique identifying number, characteristic, or code.
Additional information may be requested to resolve any conflict of interest. All identified conflicts of interest will be resolved, and disclosure will be made to activity participants.

_______________________________________________________________________________

I agree that my recommendations involving clinical medicine in this CME activity 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 scientific research referred to, reported or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection and analysis. I further agree to disclose when discussion of an unlabeled use of a project or investigational use not yet approved occurs during the course of the presentation.
ELECTRONIC SIGNATURE By entering your name, you are electronically signing this agreement and authorization of the specified document above. *

First Name Last Name
Please Upload Your CV, resume, or professional/academic bio *
Provide a photo (head shot) if you are speaking at a symposium or annual conference. Not needed for grand rounds, journal club or case conference activities.
Please provide a 50 word bio if you are speaking at a symposium or annual conference. Not needed for grand rounds, journal club or case conference activities.

0/50
Should be Empty:

	Never	Less than 5 times/year	5-10 times/year	more than 10 times/year
How often do you speak on behalf of the company for product specific education?
How often do you receive an honorarium for a CME/CNE presentation that is funded by the company?

	Yes	No
I will support my presentation and clinical recommendations with the "best available evidence" from medical literature.
I will refrain from making recommendations, regarding products or services, e.g. limit presentations to pathophysiology, diagnosis, and/or research findings.
I will not include ACCME defined commercial interest logos in my presentation.
I will not use brand names in my presentation (only generic names)/
My presentation will be fair and balanced. Not favoring a specific brand/company/or commercial interest.

Ascentist Physicians Group
Belton Regional Medical Center
California Clinical Forensic Medical Training Center
Children’s Mercy Hospital and Clinics
CNOC
INMED
Kansas City Dermatological Society (KCDS)
Kansas City Clinical Neuroscience Society (KCCNS)
The Kansas City Society of Ophthalmology and Otolaryngology(KCSO&O)
KCSO&O Journal Club
Kansas Society of Dermatology & Dermatologic Surgery(KSDDS)
Kansas City Surgical Society(KCSS)
KU Eye Center
Lee’s Summit Medical Center
Research Belton Hospital
Research Foundation
Research Medical Center
Retina Institute
St Louis Ophthalmological Society
Saint Lukes Care
Saint Luke’s Health System
Signature Healthcare Foundation
Truman Medical Center
UMKC
Western Missouri Medical Center
Other

	Yes	No
To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.
I will recuse myself from planning activity content in which I have a conflict of interest.

Disclosure of Relevant Financial Relationships

Consent to Record

Declaration