CME Financial Disclosure and Conflict of Interest Attestation - American Osteopathic College of Dermatology

Anyone involved with the content of an AOCD-sponsored CME activity must complete and sign this form. Your submission is timestamped and recorded for accreditation compliance.

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ANYONE INVOLVED WITH THE CONTENT OF A CME ACTIVITY SPONSORED BY THE AOCD MUST COMPLETE AND SIGN THIS FORM
(Speakers, Panelists, Committee Members, Residents, Fellows, etc.)

I understand that the American Osteopathic College of Dermatology (AOCD) endorses the Guidelines of the American Osteopathic Association (AOA) and the Standards of the Accreditation Council for Continuing Medical Education (ACCME). Therefore, faculty or anyone involved in the planning or presentation of content for a CME activity must disclose the presence of any financial relationships held within the previous 24 months with ineligible companies (definition included below).

Significant financial relationships include receiving (from an ineligible company) research grants, consultancies, honorarium and travel, or other benefits or having self-managed equity in a company. AOCD reserves the right to reject proposed presenters with substantive conflicts of interest. We ask that you disclose all financial relationships, regardless of the amount, with ineligible companies, regardless of the potential relevance of each relationship to the presentation.

Speakers are also expected to openly disclose any off-label, experimental, or investigational use of drugs or devices discussed in their presentation.

Financial relationships of your spouse or partner, which you are aware of, for this purpose, are considered yours and must be included.

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.

Section A: General Activity & Participant Information

Conference Title(Required)

Enter the official conference title.

Presentation Title #1(Required)

Primary lecture or session title.

Presentation Title #2

Secondary lecture or session title, if applicable.

Presentation Title #3

Additional lecture or session title, if applicable.

Role in Activity(Required)

Planning Committee

Speaker/Presenter

Panel Moderator

Other

Select your role in this CME activity.

Other Role(Required)

Please specify your role.

Name and Credentials(Required)

Full name and degrees (e.g., DO, MD, FAOCD).

Professional Title(Required)

Official title.

Organization/Institution(Required)

Primary institution or practice name.

E-mail Address(Required)

Primary contact email. Used to send you a copy of this attestation.

Phone Number(Required)

Primary contact phone.

Full Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Complete street address, city, state, ZIP.

Section B: Financial Relationship Disclosure

Statement: Within the past twelve months, I and/or my spouse/significant other have received support from or had a relationship with the following commercial interests/ineligible companies (indicate all that apply). Disclosure should include relationships in any amount. (Note: This excludes stocks owned in a diversified mutual fund or a managed portfolio.)

Primary Disclosure Selection(Required)

I do not have any financial relationships to disclose

I have the following financial relationships to disclose

Select one. Choosing the second option opens the disclosure grid below.

Row 1 — Commercial Interest (Company Name)(Required)

Name of the ineligible company.

Row 1 — Relationship Type(s)(Required)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Select all that apply for this company. Stock ownership excludes stocks owned in a managed portfolio.

Row 2 — Commercial Interest (Company Name)

Row 2 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 3 — Commercial Interest (Company Name)

Row 3 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 4 — Commercial Interest (Company Name)

Row 4 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 5 — Commercial Interest (Company Name)

Row 5 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 6 — Commercial Interest (Company Name)

Row 6 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 7 — Commercial Interest (Company Name)

Row 7 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 8 — Commercial Interest (Company Name)

Row 8 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 9 — Commercial Interest (Company Name)

Row 9 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Row 10 — Commercial Interest (Company Name)

Row 10 — Relationship Type(s)

Speakers Bureau

Consultant

Stock Ownership

Research Grant

Employee

Royalties and/or Patents

Other

Additional Disclosures Attachment

Accepted file types: pdf, xlsx, csv, docx, Max. file size: 15 MB.

If you have more than 10 commercial relationships to disclose, please upload a comprehensive list document here. Accepted formats: .pdf, .xlsx, .csv, .docx. Max file size: 15 MB.

Additional Information / Expired Relationships

Please describe any additional relevant information below, including if any of the relationships reported have ended.

Section C: Unapproved Uses & Ineligible Company Materials

Off-Label / Unapproved Usage(Required)

Yes

I will be discussing a drug or medical device that has not been approved by the FDA and/or will be discussing off label usage.

Please describe the off-label or unapproved usage(Required)

Ineligible Company Presentation Materials(Required)

Yes

I will be using slides, scripts and/or other presentation materials that were created by an ineligible company.

Please describe the ineligible company materials(Required)

Section D: Content Validation Attestations

Please attest Yes or No to each statement below.

1. Unbiased & Balanced Content(Required)

Yes

I understand that the information presented to the learner must be unbiased, scientifically balanced, and based on best available evidence in medicine. I agree to present all reasonable clinical alternatives when making practice recommendations. I attest that relationships with commercial interests will not influence or bias my presentation and/or planning of the CME activity.

2. Scientific Design & Analysis(Required)

Yes

All scientific research referred to, reported, or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection, and analysis.

3. Direct Payment Prohibition(Required)

Yes

I attest that I will not accept any payment or reimbursement for this presentation directly from any commercial interest. I understand that all payments and reimbursements must be made by the accredited provider or authorized educational partner.

Section E: Mandatory Operational Compliance Agreements

Please agree Yes or No to each item below.

1. Trade Name Restrictions(Required)

Yes

Avoid the use of trade names in my presentation. If I determine that it is important to clarify via the use of trade names, trade names from all available companies should be included, not just trade names from a single company.

2. Peer Review & References(Required)

Yes

If requested, provide appropriate peer-reviewed journal references which support clinical or practice recommendations. I understand that my CME presentation may be evaluated by participants for fair balance (e.g. degree of commercial bias) and that enduring materials (if applicable) will be peer-reviewed for fair balance and validation of content and may be edited accordingly.

3. Unlabeled Product Disclosure(Required)

Yes

Disclose to the program audience when products/services are not labeled for the use under discussion or when the products are still under investigation.

4. HIPAA Compliance(Required)

Yes

Comply with patient confidentiality requirements as outlined in the Health Insurance Portability and Accountability Act (HIPAA).

5. Copyright Clearance(Required)

Yes

Obtain the necessary copyright permission(s) if any portion of my CME activity materials that I prepare is not my original work or for which I do not hold the copyright.

Section F: Signature & Attestation

Electronic Signature(Required)

Type your full legal name to serve as a binding signature.

Date(Required)

Date of signature.

Reference Annex: Glossary of Terms

Ineligible Company

The ACCME defines an "ineligible company" as any entity producing, marketing, selling, re-selling, or distributing health care products used by or on patients. These companies are ineligible to be accredited in the ACCME System. The ACCME does not consider providers of clinical service directly to patients to be ineligible companies. For more information, see www.accme.org.

Financial relationships

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. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.

Relevant financial relationships

ACCME focuses on financial relationships with ineligible companies in the 24-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines "relevant financial relationships" as financial relationships in any amount occurring within the past 24 months with an ineligible company whose products or services are relevant to the content for which an individual can control. Circumstances create a relevant financial relationship when an individual has an opportunity to affect CME content about products or services of an ineligible company with which he/she has a financial relationship.

Continuing Medical Education (CME)

Continuing medical education consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.