ASCP Financial Relationship Collection Form

Financial Relationship Collection Form
As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form below and return it to ASCP. The 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. Thank you for your diligence and assistance. If you have questions, please contact us at melissa.lord@ascp.org.

For more information, visit accme.org
Name of Individual*
Title of Continuing Education*
Date of Education*

MonthDayYear
Date
Location of Education (City/State or Online)*
INDIVIDUAL’S PROSPECTIVE ROLE(S) IN EDUCATION
Identify the prospective role(s) that this person may have in the planning and delivery of this education (choose all that apply)*

Planner (Examples: planning committee, staff involved in choosing topics, faculty, or content)Teacher, Instructor, FacultyAuthor, WriterReviewerOther
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.
IN THE PAST 24 MONTHS, I HAVE NOT HAD ANY FINANCIAL RELATIONSHIPS WITH ANY INELIGIBLE COMPANIES.
ENTER THE NAME OF INELIGIBLE COMPANY

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies, visit accme.org/standards.
ENTER THE NATURE OF FINANCIAL RELATIONSHIP

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 ENDED?

If the financial relationship existed during the last 24 months, but has now ended, please answer YES in this column. This will help the education staff determine if any mitigation steps need to be taken. If the financial relationship has not yet ended, please answer NO.

	NAME OF INELIGIBLE COMPANY	NATURE OF FINANCIAL RELATIONSHIP	HAS RELATIONSHIP ENDED? (YES/NO)
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Please use this field to enter any additional financial relationships that did not fit in the previous chart.
I ATTEST THAT THE ABOVE INFORMATION IS CORRECT AS OF THE DATE OF THIS SUBMISSION:*

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This form was adapted from the Toolkit for the Standards for Integrity and Independence in Accredited Continuing Education © 2020 by the Accreditation Council for Continuing Medical Education (ACCME®)
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Financial Relationship Collection Form

INDIVIDUAL’S PROSPECTIVE ROLE(S) IN EDUCATION

ENTER THE NAME OF INELIGIBLE COMPANY

ENTER THE NATURE OF FINANCIAL RELATIONSHIP

HAS THE RELATIONSHIP ENDED?