USE THIS - ASNR Financial Discloure Form


Conflict of Interest Disclosure Form

SECTION 1: Demographic Data

Role in Educational Activity:(Check all that apply) *

Please explain "other"
Full Name with Credentials/Degree: *
Street Address *
City *
State or Province *
Zip Code
Country
Current Employer and Position/Title: *
Phone Number
Email

SECTION 2: Conflict of Interest

The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity.  The AKHCE Director of Accreditations is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity.

* COMMERCIAL INTEREST is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients.

Commercial Interest Organizations are ineligible for accreditation.

An organization is NOT a Commercial Interest Organization* if it is:

  • A government entity;
  • A non-profit (503(c)) organization;
  • A provider of clinical services directly to patients, including but not limited to hospitals, health care agencies and independent health care practitioners;
  • An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to provides or developers of electronic health information systems, database systems, and quality improvement systems;
  • A non-healthcare related entity whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on patients.
  • A liability insurance provides;
  • A health insurance provider;
  • A group medical practice;
  • An acute care hospital (for profit and not for profit);
  • A rehabilitation center (for profit and not for profit);
  • A nursing home (for profit and not for profit);
  • A blood bank; or
  • A diagnostic laboratory.

(*Reference Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 (www.accme.org) - This definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activites and consistency with the ACCME definition)

All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

**Relevant relationships, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.

  • Relationships with any commercial interest of the individual's spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.
  • Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
  • Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.
Is there an actual, potential or perceived conflict of interest (relevant financial relationship) for yourself or spouse/partner? *

Clear Selection

Categories
- Salary - S
- Royalty - R
- Stock - ST
- Speakers Bureau - SB
- Consultant - C
- Contracted Research - CR
- Other - O

Name of Financial Interest
Disclosure 1:

Clear Selection
Person with relevant relationship.
Name of Financial Interest
Disclosure 2:

Clear Selection
Person with relevant relationship.
Name of Financial Interest
Disclosure 3:

Clear Selection
Person with relevant relationship
Name of Financial Interest
Disclosure 4:

Clear Selection
Person with relevant relationship.
Name of Financial Interest
Disclosure 5:

Clear Selection
Person with relevant relationship.
Name of Financial Interest
Disclosure 6:

Clear Selection
Person with relevant relationship.

** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing education activity.

If all relationships do not fit in above the table, please include on separate sheet of paper.

SECTION 3: Statement of Understanding

Signature *

Expertise - Presenter/Faculty/Author/Content Reviewer

Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the CME Office may request additional documentation.)
(Maximum characters: 2000)
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