FACULTY DISCLOSURE FORM

FACULTY DISCLOSURE FORM
Name*

First NameLast Name
Credentials (i.e. MD, RD, PharmD, RN, etc.)*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Activity Title*
DISCLOSURE OF FINANCIAL RELATIONSHIPS

As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. 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.
Within 24 Months of the date of this form, have you had a financial relationship or other affiliation with an ineligible company?*

YesNo
NATURE OF THE FINANCIAL RELATIONSHIPS

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.

The following questions are for those on a Speakers’ Bureau (SB), or employed by, an ineligible company:
Are you CURRENTLY on a Speakers’ Bureau or employed by an ineligible company?

YesNo
Provide the date of termination if you were previously on a Speakers’ Bureau or employed by an ineligible company in the past 24 months but have since severed the relationship:

MonthDayYear
Date
Have you participated in company-provided speaker training related to your proposed topic?

YesNo
Did you receive an honorarium or consulting fee for participating in this training?

YesNo
Did the company provide you with proprietary slides/materials for your presentations?

YesNo
As faculty for the CE Provider seeking accreditation, do you intend to use slides/materials or content provided by an ineligible company for your presentation/handout?

YesNo
Will your topic involve information or data obtained through training from an ineligible company?

YesNo
DISCLOSURE OF OFF-LABEL/INVESTIGATIONAL USES OF PRODUCTS
Will the content of your material(s)/presentation(s) in the CE activity include discussion of unapproved or investigational uses of products or devices?*

YesNo
Please specify any off-label or investigational use:
COMPLIANCE WITH NKF ACCREDITATION POLICY

Please initial each statement below indicating you have read, understand, and are willing to comply
I attest that the CE content for which I am responsible will be evidence-based, fair and balanced, unbiased, and free from control of an ineligible company.*
No promotional activities may occur during CE events. This includes distribution of product brochures or product information in conjunction with the educational activity or handouts. No slides or handouts developed by an ineligible company may be used during presentations. I agree to not promote any specific proprietary or ineligible company interest in my role as planner or faculty/speaker.*
I have not and will not accept payments or reimbursements from an ineligible company for my participation in this activity.*
I understand that an employee of an ineligible company may NOT serve as a faculty or planner of CME/CE accredited by NKF if the educational content that the employee controls relates to the products and/or services of the ineligible company employer. If the content DOES NOT relate to the products and/or services of the ineligible company, the employee may be eligible to serve as speaker or planner, but the educational content must be reviewed (must be sent with the application) before approval of CE credit will be considered.*
I understand that if I serve on a Speakers’ Bureau for the same clinical area as the education activity I plan to provide, and for which accreditation is being requested, my educational activity material(s) must be submitted for a full independent review at the time of the application submission before approval for CE credit will be considered.*
I understand that if I engage in a financial relationship with an ineligible company after the CE program has been granted CE accreditation, but before the educational activity has been implemented/delivered, I must alert NKF and provide a new disclosure form. A second review for approval will become necessary before the activity can be delivered.*
I understand that if changes are made to my educational presentation/material(s) after the CE program has been granted CME/CE accreditation, but before the educational activity has been implemented/delivered, I must alert NKF and provide information/documentation on the changes. A second review for approval will become necessary before the activity can be delivered.*
I understand that failure to disclose, false disclosure, or inability to resolve conflicts of interest will require NKF to identify a replacement or not offer CE credit for this activity.*
Signature*
Note: By signing this application electronically, I certify the information provided is accurate. I understand that an electronic signature has the same effect and can be enforced in the same way as a written signature.
Today's Date*

MonthDayYear
Date
Should be Empty:

	Name of Ineligible Company	Nature of Financial Relationship (e.g., employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties, executive role, and ownership interest)	Has the Relationship Ended? Y/N	If the relationship has ended, what was the end date?
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FACULTY DISCLOSURE FORM

DISCLOSURE OF FINANCIAL RELATIONSHIPS

NATURE OF THE FINANCIAL RELATIONSHIPS

DISCLOSURE OF OFF-LABEL/INVESTIGATIONAL USES OF PRODUCTS

COMPLIANCE WITH NKF ACCREDITATION POLICY