Conflict of Interest/Disclosure Declaration Statement

Guidelines

All individuals in a position to control the content of this Creighton University Office of Continuing Education (CUCE) activity must complete this form. This includes speakers, poster presenters, and planning committee members.

CUCE Program: Teaching Prevention 2021

Program Date: March 8-10, 2021

If you have 2 presentations accepted you must enter both. Invited plenary speakers just enter "Plenary"

Presentation 1 Number:

Presentation 2 Number:

First Name: *

Last Name *

Degrees *

Email: *

Role: *

Speaker/Presenter

Planning Committee

Moderator

Staff

Creighton University Conflict of Interest Policy:
Accredited as a Jointly Accredited Provider by the Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), and accredited by the American Dental Association Continuing Education Recognition Program (ADA CERP), Creighton University Health Sciences Continuing Education must insure balance, independence, objectivity, and scientific rigor in all individually provided or jointly provided educational activities.

Individuals who are in a position to control content of this educational activity are expected to disclose any relationships with commercial interest organizations that may pose a real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education activity. The intent of this disclosure is not to prevent individuals who have a significant financial or other relationship from participating in this activity, but rather to provide listeners information in which they may form their own judgments. ACCME defines commercial interest as: “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients”. The ACCME does not consider providers of clinical service directly to patients as commercial interest. A commercial interest is not eligible for ACCME accreditation.

Please carefully review the above Creighton University Policy on Conflict of Interest. Your completion of this form is your Declaration of Disclosure. Your signature indicates your agreement to follow the Policy and disclose affiliations with companies that may have an impact on your presentation at this CUCE activity.

Do you have an affiliation with a commercial interest organization that will have an impact on the presentation(s) you are giving at this CUCE activity? *

Yes

IF YES, list the names of proprietary entities producing health care goods or services, marketing, re-selling, or distributing, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse have, or have had, a relevant financial relationship within the past 12 months that will have an impact on your presentation at this CUCE activity:

Affiliation/Financial Interest

	Name of
Grant/Research Support	Name of
Consultant	Name of
Speakers' Bureau	Name of
Major Stock Shareholder	Name of
Other Financial or Material Support	Name of

Affiliation/Financial Interest

	Name of
Grant/Research Support	Name of
Consultant	Name of
Speakers' Bureau	Name of
Major Stock Shareholder	Name of
Other Financial or Material Support	Name of

I have read the Conflict of Interest/Disclosure Declaration Statement information and agree to abide by this policy. *

clear

By entering your name, you are submitting an electronic version of your signature.

Date *

Letter of Attestation

Creighton University Office of Continuing Education

Letter of Attestation

If you have any questions regarding your ability to comply, please contact Vera Cardinale, APTR Director of Training and Education, at vsc@aptrweb.org or 202-463-0550 x120 as soon as possible.

Please indicate your understanding of and willingness to comply with each statement below. *

	Agree	Disagree
I have disclosed to the Creighton University Office of Continuing Education all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.	Agree	Disagree
The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.	Agree	Disagree
I have not and will not accept any honoria, additional payments or reimbursements beyond that which have been agreed upon directly with Creighton University Office of Continuing Education.	Agree	Disagree
I understand that the Creighton University Office of Continuing Education will need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.	Agree	Disagree

Please indicate your understanding of and willingness to comply with each statement below. *

	Agree	Disagree	N/A
If I am presenting at a live event, I understand that a CUCE monitor will be attending the event to ensure that my presentation is educational, and not promotional, in nature.	Agree	Disagree	N/A
If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in CUCE in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.	Agree	Disagree	N/A
If I am discussing specific health care products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.	Agree	Disagree	N/A
If I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA for labeling or advertising.	Agree	Disagree	N/A
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.	Agree	Disagree	N/A
If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.	Agree	Disagree	N/A

I have carefully read and considered each item in this form and have completed it to the best of my ability. *

clear

By entering your name, you are submitting an electronic version of your signature.

Date *

Program Name: Teaching Prevention 2021

Glossary of Terms

Commercial Interest
The ACCME defines a ‘commercial interest’ as any entity producing, marketing, re-selling, or distributing health care goods or services, consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. 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. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant Financial Relationships
ACCME focuses on financial relationships with commercial interests in the 12-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 12 months that create a conflict of interest.

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.

Comments

0/400 words