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Osler Institute Disclosure

Disclosure of Financial Relationships 
for Continuing Professional Education

Name and Degree (Required)
Select your role (Choose all that apply)

CRITERIA FOR DISCLOSURE OF FINANCIAL RELATIONSHIPS WITH INELIGIBLE  COMPANIES IN CONTINUING EDUCATION (CME/CE)
1. Instructors, planners, content reviewers, or others who may control educational content of a CME/CE activity are required to disclose all financial relationships that you have had in the past 24 months with ineligible companies** (i.e., any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients). 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.

  • Advertising, marketing, or communication firms whose clients are ineligible companies
  • Bio-medical startups that have begun a governmental regulatory approval process
  • Compounding pharmacies that manufacture proprietary compounds
  • Device manufacturers or distributors 
  • Reagent manufacturers or sellers
  • Diagnostic labs that sell proprietary products
  • Growers, distributors, manufacturers, or sellers of medical foods and dietary supplements
  • Manufacturers of health-related wearable products
  • Pharmacy benefit managers
  • Pharmaceutical companies or distributors


2. You are to disclose all financial relationships that fit the above definition in any amount that has been received over the past 24 months.
3. Financial relationships with governmental agencies (e.g., the NIH) and organizations that do not fit the above definition do not have to be disclosed.
4. Honoraria or consulting funds received from a CE provider do not have to be disclosed, even though those funds may have been provided to that CME/CE provider through an educational grant from a commercial interest.
5. If you are a principal investigator for an ineligible company, you must report that research relationship below under "Contracted Research" even if those funds came to your institution and are managed by said institution.
6. In accordance with ACCME, ANCC, and ACPE requirements, failure to provide disclosure information in a timely manner will result in the disqualification of the potential planner, course director, moderator, faculty, presenter, author, or reviewer from this activity.

PART I: NATURE OF FINANCIAL RELATIONSHIPS:

Within the past 24 months, have you received support from, or had a relationship with, an INELIGIBLE COMPANY?*

Please indicate in the list of types of financial relationships below - the name of the ineligible company(ies) with whom you have had a financial relationship within the past 24 months. 
Only answer this question if the following condition is met: Answer was ' Yes. I have at present and/or have had within the past 24 months a financial relationship with an ineligible company as defined above.**    

 
Salary
Royalty
Receipt of Intellectual Property Rights/Patent Holder
Consulting Fee
Speakers Bureau
Fees for Non-CME/CE Services Received Directly from a Ineligible Company or its Agent.
Contracted Research (Grants to your institution are NOT reportable unless you are a Principal Investigator.)
Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds)
Other (please describe):
If your relationship has ended with the ineligible company(s) listed above please enter the date upon which that relationship ended.

If you reported relationships in the chart above, will any of these relationships impact your ability to present an unbiased presentation?

PART II: ATTESTATION OF CME/CE VALUE STATEMENTS

Please indicate your understanding of and willingness to comply with each statement below. If you require clarification of these statements or have questions regarding your ability to comply, please contact the CME/CE Office immediately.*

Agree Disagree
I have disclosed all financial relationships and I will disclose this information to learners
The content and/or presentation of the information with which I am involved will promote quality or improvements in health care 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 balanced, evidence-based and commercially unbiased.
I have not and will not accept any honoraria, additional payments or reimbursements directly from a commercial interest for my participation in this activity.
I understand that The Osler Institute may need to review my presentation and/or content prior to this activity, and I will provide educational content and resources in advance as requested.
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 will conform to the generally accepted standard of experimental design, data collection and analysis.
If I am discussing specific healthcare 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.
If I have been trained or utilized by a commercial interest 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.
If I am presenting research funded by a commercial interest, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the funding company.

My signature (or typed name for e-filing) below indicates that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided on this form will be shared with learners prior to their engagement in this CME/CE activity.

Date
 
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