To be Completed by the Planner, Faculty, or Others Who May Control Educational Content
Please disclose all financial relationships 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 with the ineligible* companies regardless of the amount. You should disclose all financial relations regardless of the potential relevance of each relationship to the education.
Enter the name of the ineligible* company: *An ineligible company is defined as "any entity producing, marketing, reselling, or distributing healthcare products used by or used on patients."
Enter the nature of the financial relationship: Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. The principal or named investigator must disclose research funding from ineligible companies, 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 ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken.