ABOPM CME FORM Nature of Financial Relationship Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options or other ownership interest, excluding diversified mutual funds) or other financial benefit. Role(s) Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities (please specify). Conflict of Interest Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship. An individual who refuses to disclose financial relationships with be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for the development, management, presentation or evaluation of the CME activity Name and Degree(s) Title of CME Activity for which you are involved (e.g. Hospitalist CPD, Grand Round, CME/GME, etc.) NOTE: If you are a member of the network CME Committee, state "CME Committee" as your answer Institutional Affiliation Inspira Health, Penn Cardiology, Cooper Hospitalist Program, etc Role in Activity (Check all that apply) Course Director Moderator Reviewer Presenter/Author Planner Subject Matter Expert In the past 24 months, have you had any financial relationships with any ineligible companies? Yes No Faculty and Planner Agreement for CME Activity Directions: Read the ACCME Content Validity Values Statement below, then read and check all of the following boxes to attest to your understanding of and willingness to comply with the corresponding statement; accept terms and date form. ACCME Content Validity Values Statement: All recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contra-indications in the care of patients. All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. Check all of the following boxes to attest to your understanding of and willingness to comply with the ACCME Content Validity Values Statement. Best Available Evidence and ACCME Content Validation Statement: All clinical recommendations that I make for patient care as part of my planning and/or CME activity materials will be based on the best available evidence and the content will be in compliance with ACCME's Content Validation Statement. Sources and Limitations of Data, Off-Label Use Disclosure: To the extent practical, recommendations involving clinical medicine in this CME activity will be substantiated by peer-reviewed sources. I will make meaningful disclosure to the attendees if products or procedures I discuss are off-label, unlabeled, experimental, and/or investigational (not FDA approved), and any limitations on the information that I present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. Scientific Integrity: All scientific research referred to, reported or used in support or justification of a patient care recommendation will conform to generally accepted standards of experimental design, data collection and analysis. Free of Commercial Bias: CME content presented to learners will be free of commercial bias. No product, service, or therapeutic option will be over-represented when comparing competing products, services, and therapeutic options. When appropriate, generic names or trade names from several companies will be used. Payments: I have not and will not accept an honorarium, additional payment, or reimbursements except for payments from CME provider or authorized representative for any participation in this activity. I understand that all payments to me will be made in compliance with the provider's Policy on Honoraria and Expense Reimbursement. Serve the Public Interest: Any selection of topics, instructional content and personnel I make for this CME activity will be done to serve the public interest by improving the quality of healthcare. To the best of my ability, I will not let any personal financial relationships influence this selection process. Presentations must give a balanced view of therapeutic options: Use of generic names will contribute to this impartiality. If your presentation includes trade names, where available trade names from several companies should be used, not just trade names from a single company. Logos from commercial interests are never permitted on any course materials including presentation slides. Your presentation/materials will be evaluated by attendees for fair balance, objectivity and scientific rigor. Content Validation Review: I understand that my CME Activity presentation/materials may be prospectively peer-reviewed for fair balance and validation of content and may require editing. HIPAA Compliance: I will remove all patient identifiers (name, birth date, address, phone number, medical record number, account number, social security number, etc.) from my presentation materials. I will not use identifiable photographs of patients, unless i have obtained written patient permission. Ancillary marketing and nonaccredited activities - defined 30 minute interval must separate accredited activities and marketing or nonaccredited activities if they are held in the same educational space. Date MM DD YYYY Thank you!
