Speaker Information

The MidMichigan Health System CME Program must ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. Therefore, all participating activity organizers, program directors, committee members, and lecturers in a sponsored event are expected to disclose any relevant financial relationships. The intent of this disclosure is not to prevent a speaker, presenter, event organizer or committee member who may have influence over material from contributing, but rather to provide activity organizers and listeners with information on which they can make their own judgments. It remains for the audience to determine whether the speaker’s interests or relationships may influence the presentation with regard to exposition or conclusion.

Although organizers and committee members may not actually present at a planned event, their responsibility of program planning, oversight and credit approval places them in positions to potentially influence educational events. The significance to influence, therefore requires full disclose of potential conflicts of interests in the fulfillment of their responsibilities.

Please disclose all ﬁnancial relationships that you’ve had in the past 24 months with ineligible companies (see deﬁnition below). For each ﬁnancial relationship, enter the name of the ineligible company and nature of the ﬁnancial relationship(s). There is no minimum ﬁnancial threshold; please disclose all ﬁnancial relationships, regardless of the amount, with ineligible companies. Please disclose all ﬁnancial relationships regardless of the potential relevance of each relationship to the education.

An ineligible company is any entity whose primary business is producing, marketing, selling, re‐selling, or distributing healthcare products used by or on patients.

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 grants and manages the funds.

Have you (or your spouse/partner) had a financial relationship in the last 24 months with an ineligible company that will be discussed in the CME activity or in your presentation?*

YesNo

	Commercial Interest Name/Description	Nature of Relevant Financial Relationship - What was received? (do not need $ amount)	Nature of Relevant Financial Relationship - For what role?	Completion Date or End Date (if applicable)
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It is the Speaker's responsibility to disclose any presentation of off-label uses of a product. Do you anticipate your presentation to include discussion of any off-label uses of a product?*

YesNo

Please Explain:

I attest to the following:

I will prepare fair & balanced presentations that are objective & scientifically rigorous. Content – including therapeutic options, recommendation, or emphasis – will be well‐balanced, evidence based where possible & unbiased. Source and type of evidence will be made clear to the participants and be HIPAA compliant, i.e., I will only use de‐identified patient information. No single product or service will be over represented when other equal but competing products or services are available for inclusion.
I will use generic names to the extent possible when discussing specific health care products or service. If I need to use trade names, I will use trade names from several companies when available, & not just trade names from any single company.
If I have been trained or utilized by a commercial entity or its agent as a speaker for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.
If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles & methods, & will not promote the commercial minterest of the funding company.
The handouts and slides will not include my company logo other than on the first slide (the copyright symbol may be included on each of the slides.)
I will not include any advertising, trade names or product‐group messages in any of the educational materials for this CE activity (slides, abstracts, handouts, etc.).
I understand that activity planners may need to review my presentation &/or content prior to the activity & I will provide educational content and resources in advance as requested.
I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with Sponsor of this activity.
I understand that participants will be asked to evaluate these requirements.

Printed Name:*

First NameLast Name

Date*

CME Disclosure Form