Speaker Conflict of Interest Disclosure

  • Speaker Conflict of Interest Disclosure

  • Date of Activity*
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  • Per ACPE, all persons in a position to control the content of this educational activity (either as a planner or content expert/presenter/speaker) must disclose to CE SYNERGY, LLC any relationship of a financial, professional, or personal nature with an ineligible company from the past 24 months. The definition of an ineligible company is as follows: those whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients.

    The intent of this disclosure is not to prevent a planner with affiliations to an ineligible company from planning an educational activity, or to prevent a presenter/speaker with affiliations to an ineligible company from presenting, but rather to inform CE SYNERGY, LLC as the accrediting provider, of any potentially biasing relationships so that conflicts can be mitigated prior to the activity.

    It is the policy of CE SYNERGY, LLC to ensure balance, independence, objectivity, and scientific rigor in all of its continuing pharmacy education activities. CE SYNERGY, LLC will identify, determine, and if necessary, mitigate, all conflicts of interest. Prior to the time of the presentation, all relevant conflicts of interest will be disclosed to the audience in writing.

  • Please specify the categories below where any financial, professional, or personal relationship(s) exists.

  • 1. Employment*
  • 2. Elected or voluntary leadership position in professional organization, including committee membership*
  • 3. Research Funding*
  • 4. Paid Consultant or Member of an Advisory Board or Review Panel*
  • 5. Speaker's Bureau*
  • 6. Major Stock or Investment Holder*

  • Please indicate your understanding of, and willingness to comply with, each statement below by checking the appropriate box. If you have any questions regarding your ability to comply, please contact the CE Administrator for this event or email info@cesynergy.com as soon as possible.

  • I have disclosed to the CE Synergy, LLC  all financial relationships, and I will disclose this information to learners verbally and in print.*
  • The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of an ineligible company. Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.*
  • I have not, and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with CE Synergy, LLC.*
  • I understand that CE Synergy, LLC will review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.*
  • If I am presenting at a live event, I understand that a CE Synergy, LLC monitor will attend the event to ensure that my presentation is educational, and not promotional, in nature.*
  • If I am discussing specific health care 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.*
  • If I have been trained or utilized by an ineligible company, or its agent as a speaker (e.g., speaker’s bureau) for any ineligible company, the promotional aspects of that presentation will not be included in any way with this activity.*
  • If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted with the profession of medicine as adequate justification for their indications and contraindications in the care of patients. I will convey the limitations of the content being taught and the severe and most common risks of treatments that are discussed.*
  • If I am presenting research funded by an ineligible company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the ineligible company. All scientific research referred to, reported or used in the activity in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection, and analysis.*
  • 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 for labeling or advertising.*

  • I have carefully read and considered each item in this form, and have completed it to the best of my ability.

  • Date*
     / /

  • All material on the CE Synergy, LLC forms, website, and/or in its publications, including design, text, images, logos, and sounds, are
    owned by CE Synergy, either through copyright or trademark, unless otherwise indicated. All rights are reserved by CE Synergy. Content may not be copied, reproduced, transmitted, distributed, downloaded, or transferred in any form or by any means without CE Synergy’s prior written consent, and with express attribution to CE Synergy. Copyright infringement is a violation of federal law subject to criminal and civil penalties. CE Synergy, LLC ©2024

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