CI23 - Faculty Invitation & Financial Relationships Form

As a prospective participant, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form below and click "Submit Form" when you reach the end.

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 [email protected].

Prospective role(s) in this activity - choose all that apply*

Instructions for this form

1) Please disclose all financial relationships that you have had in the past 24 months with ineligible companies. An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. More information here.

2) 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.

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.

3) If the financial relationship existed during the last 24 months, but has now ended, please indicate in the field provided. This will help the education staff determine if any mitigation steps need to be taken.

Relationships Declaration*

In the past 24 months, I have had financial relationships with ineligible companies.
In the past 24 months, I have not had any financial relationships with any ineligible companies.

Financial Relationships*

To add additional relationships, click the plus button on the right-hand side.

Please note that your financial relationship(s) may require further mitigation. You will be notified via email if additional steps need to be taken before your participation in the activity.

Name of Ineligible Company	Nature of Financial Relationship	Has this relationship ended? Enter Yes or No

Attestation*

I attest that all of my clinical recommendations will be evidence-based and free of commercial bias (e.g., based on peer-reviewed literature and/or evidence-based practice guidelines). I will not discuss any unlabeled uses of products.

Consent*

I attest that all of the above information is correct as of this date of submission

Date*

Please click "submit form" below to submit your decline to participate.

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Faculty Invitation & Financial Relationships Form

Instructions for this form