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CME Disclosure Form

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As a sponsor accredited by the ACCME in accordance with the ACCME Standards of Commercial Support, Miami Children's Hospital must ensure all CME planners, teachers, and authors involved in the development of CME content4 disclose to the accredited provider their (or their Spouse/ Partner) relevant financial relationship2,3  with ANY ACCME-defined commercial interest1 (see ACCME Definitions below).  Persons who fail to complete this form will not participate in the CME activity.  Relevant relationships will be disclosed to the activity audience.

Fields marked with an * are required.

A. I [and/or an immediate family member including my spouse/partner] have a financial interest, arrangement or affiliation with a commercial organization (currently or within the past 12 months) that may have a direct or indirect interest in the subject matter of my presentation/participation. If YES, the financial relationships are identified as follows: (If No, go to the next question, if Yes, complete the information related to financial organization(s)) *



CME Activity Title: *


Presenter/Faculty Name: *


Email: *


Date Completed (MM-DD-YYYY): *


Session Date (MM-DD-YYYY): *


Role: *


If Other, Please Specify


Company/ Organization/ Commercial Interest Financial Relationship 1:


Organization 1 - Involved Party



Nature of the Relationship - Select all that apply to Company/Organization 1:









Other Company/Organization Relationship 1:


Company/ Organization/ Commercial Interest Financial Relationship 2:


Organization 2 - Involved Party



Nature of the Relationship - Select all that apply to Company/Organization 2:









Other Company/Organization Relationship 2:


Company/ Organization/ Commercial Interest Financial Relationship 3:


Organization 3 - Party Involved



Nature of the Relationship - Select all that apply to Company/Organization 3:









Other Company/Organization Relationship 3:


Organization 4 - Involved Party



Nature of the Relationship - Select all that apply to Company/Organization 4:









Other Company/Organization Relationship 4:


Company/ Organization/ Commercial Interest Financial Relationship 5:


Organization 5 - Involved Party



Nature of the Relationship - Select all that apply to Company/Organization 5:









Other Company/Organization Relationship 5:


If the focus of your presentation is a commercially funded study, please list the funding company or source and your affiliation with the funding company or source:


B. The following mechanisms have been identified to resolve conflicts of interest. Please check all that apply. (Presenters)






C. The following mechanisms have been identified to resolve conflicts of interest. Please check all that apply. (Planners)



D. My presentation or participation will involve comments or discussion concerning unapproved or off-label uses of a medical device or pharmaceuticals. If any unapproved or off-label uses of products will be discussed, disclosure must be made to the participants regarding the unapproved or off-label use. If you will be discussing any such uses, please indicate the products to be discussed and the unapproved and/or off-label uses. If any other comments concerning unapproved or off-label uses of products take place during your discussion, you are advised that you must disclose this information to the attendees.



Product to be discussed 1:


Unapproved or Off-Label use 1:


Product to be discussed 2


Unapproved or Off-Label use 2:


Product to be discussed 3:


Unapproved or Off-Label use 3:


Product to be discussed 4:


Unapproved or Off-Label use 4:


Product to be discussed 5:


Unapproved or Off-Label use 5


E. By checking the boxes below you acknowledge that you agree with the following representations:






Please attach your powerpoint presentation


Upload a copy of your current CV


By typing my initials in the box below, I acknowledge that I provided the correct answers to the questions on this form to the best of my abilities and hereby submit the CME Disclosure Form (Initials) *





Terms as defined by the ACCME:

1.     Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients.

2.     Financial Relationships: 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. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

3.     Relevant financial relationships: Financial relationships with commercial interests in any amount occurring within the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity that create a conflict of interest. The ACCME has not set a minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. With respect to personal financial relationships,contracted research includes research funding where the institution gets the grant and manages the funds and the person is the principal or named investigator on the grant.

4.     Individuals with potential for influence or control of CME content: Planners and planning committee members, authors, teachers, educational activity director(s), educational partner(s), and others who participate, e.g. facilitators and moderators. The ACCME considers financial relationships to create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest. The ACCME considers “content of CME about the products or services of that commercial interest” to include content about specific agents/devices, but not necessarily about the class of agents/devices, and not necessarily content about the whole disease class in which those agents/devices are used.

5.     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. With respect to financial relationships with commercial interests, when a person divests themselves of a relationship it is immediately not relevant to conflicts of interest but it must be disclosed to the learners for 12 months