Disclosure of Financial Relationships (CE)

Division of Continuing Education
Disclosure Form for Identifying All Financial Information For Faculty, Planners, and Others
Name

First NameLast Name
Activity Date

MonthDayYear
Date
Title of Activity
Individual's Prospective Role in Activity

PlannerFaculty/TeacherContent ReviewerAuthor/WriterOther
As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry/influence. KMA accreditation requirements and ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.

The Accreditation Council for Continuing Medical Education (ACCME) Standards for Integrity and Independence require all financial relationships between individuals that can control or influence the content of an activity (speakers, planning committee members, content reviewer, etc.) and ineligible companies be evaluated to determine if the possibility exists for industry influence in the learning environment of an accredited continuing educational activity. If any relationship exists, it must be mitigated prior to the activity.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below).

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s).

There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Examples of natures of relationships: Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed.

Important Note Regarding Funds from Research: Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the grant and manages the funds.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below).

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies.

You should disclose all financial relationships regardless of the potential relevance of each relationship to the education
Have you had any financial relationships with any ineligible companies (any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients) in the past 24 months?

YesNo
What are ineligible companies?

Ineligible companies are those whose primary business is producing, marketing, selling, re-selling,or distributing healthcare products used by or on patients.
What was the nature of the relationships?

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest.

Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed.

Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.
Has the relationship with the ineligible companies ended?

If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken.

Today's date: *

MonthDayYear
Date
I attest that the above information is correct as of this date of submission. *

Clear
Should be Empty:

	Name of Ineligible Company	Nature of relationship	Has the relationship ended, yes or no?
Company 1
Company 2
Company 3
Company 4
Company 5
Company 6

Disclosure Form for Identifying All Financial Information For Faculty, Planners, and Others