CORNELL
U N I V E R S I T Y
Joan and Sanford I. Weill
Medical College
Office of Continuing Medical Education
1300 York Avenue, Box 16
New York, NY 10021
Telephone: 212 746-2631
Fax: 212 746 -8180
GUIDELINES FOR PRINTED MATERIALS:
JOINT CME INFORMATION PAGE
FORM #CMEG-5A
All attendees at Weill Cornell-approved CME activities must be provided, in writing, required CME
information. When applying for credit approval for your activity, you must include a copy of this
CME Information Page along with your application. This page must include:
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Activity title, date and location
Name of the Course Director and Co-Course Director, if applicable
Identified Practice Gaps/Educational Needs
Targeted Audience
Course Objectives/Desired Outcomes
Disclosure of Commercial Support
Disclosure of Relationships/Content Validity Statement
Full Disclosure Information for all Course Directors, Co-Course Directors, Independent
Clinical Reviewers and Planning Committee Members, if applicable
Note: Any speakers who refuse to complete a faculty disclosure form prior to the activity
must be disqualified from participating as a speaker.
Accreditation Statement
Credit Designation Statement
Course Evaluation Information
Statement offering to accommodate those with special needs
The attached sample document is a template CME Information Page that should be used for every
approved CME activity. This CME Information Page must be included in the handout materials at
your activity. Enduring Materials require additional information on the CME Information Page; please
refer to the Enduring Materials section of the CME website for instructions:
http://www.med.cornell.edu/education/programs/edr_mat.html
Of particular importance is the section on “Full Disclosure.” Please note that disclosure MUST be
made to your audience using this format regardless of whether or not a speaker has any relationships to
disclose. In addition, you must note if there will be discussions of off-label or investigational uses of
products or devices. This data must be consistent with the Full Disclosure Forms signed by your
faculty members and planners.
The Office of CME is available to assist you with the creation of this document.
* EXAMPLE * EXAMPLE * EXAMPLE * EXAMPLE*
CONTINUING MEDICAL EDUCATION
GENERAL INFORMATION
16TH ANNUAL FAMILY PRACTICE SYMPOSIUM
Saturday, October 14, 2010
Weill Cornell Medical College
Uris Auditorium
John Smith, M.D., Course Director
IDENTIFIED PRACTICE GAPS/EDUCATIONAL NEEDS
PLEASE NOTE: This statement of need should include an epidemiological statement (on the current
state of knowledge, skills, competence, practice, or patient outcomes) and what would be expected (the
desired/ideal state of knowledge, skills, competence, performance, patient outcomes).
TARGETED AUDIENCE
This course is designed for family practitioners and primary care physicians as well as nurses and other
allied health professionals who specialize in the treatment and diagnosis of common medical illnesses
in the adult and pediatric community.
OBJECTIVES/DESIRED OUTCOMES
It is intended that this Weill Cornell CME activity will lead to improved patient care, including
improvements in knowledge, competence, or performance. At the conclusion of this activity,
participants should be able to:
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Better identify symptoms of the common cold
Provide better treatment to children and adults who present with strep throat
Incorporate new research findings and develop new strategies for treating Lyme disease
Promote discussions on the importance of vitamin supplements in daily life and how this will
lead to greater patient well being
Weill Cornell Medical College gratefully acknowledges funding in part provided by unrestricted educational
grants from:
ACME PHARMACEUTICALS, INC., XYZ DEVICE MFG., VITAMINS-R-US, INC.
DISCLOSURE OF RELATIONSHIPS/CONTENT VALIDITY
It is the policy of Weill Cornell Medical College to adhere to ACCME Criteria, Policies, and Standards
for Commercial Support and content validation in order to ensure fair balance, independence, objectivity,
and scientific rigor in all its sponsored activities. All speakers, Course Directors, Co-Course Directors,
planners, reviewers, and staff members participating in sponsored activities are expected to disclose
relevant financial relationships pertaining to their contribution to the activity. Relationship information is
analyzed to determine whether conflicts of interest exist. All conflicts of interest are resolved prior to
participation in the planning or implementation of this activity. Presenters and authors are also expected
to disclose any discussion of (1) off-label or investigational uses of FDA approved commercial products
or devices or (2) products or devices not yet approved in the United States.
WCMC CME activities are intended to be evidence-based and free of commercial bias. If you have any
concerns, please call the Office of Continuing Medical Education at 212-746-2631 to anonymously
express them.
Course Director
John Smith, M.D.
 Speaker’s Bureau: Pfizer
 Will not be discussing the off-label or investigational use of products
Course Co-Director (if applicable)
Jennifer Smith, M.D.
 Has no relevant financial relationship to disclose.
 Will not be discussing the off-label or investigational use of products
Independent Clinical Reviewer (if applicable)
Sarah Jones, M.D.
 Has no relevant financial relationship to disclose.
 Will not be discussing the off-label or investigational use of products
Course Faculty
Peter McDonald, M.D.
 Has no relevant financial relationship to disclose.
 Will not be discussing the off-label or investigational use of products
Marilyn Johnson, M.D.
 Speaker’s Bureau: Astra Zeneca
 Research Support: Lilly Oncology and Amgen
 Consultant: Bristol Myers Squibb
 Will be discussing the off-label or investigational use of products
Planning Committee
Joseph Brown, M.D.
 Has no relevant financial relationship to disclose.
 Will not be discussing the off-label or investigational use of products
Lisa Jones, M.D.
 Speaker’s Bureau: Astra Zeneca
 Research Support: Merck
 Consultant: Bristol Myers Squibb
 Will be discussing the off-label or investigational use of products
Course Coordinator
David Smith, M.P.H.
 Has no relevant financial relationship to disclose.
 Will not be discussing the off-label or investigational use of products
CME Staff
 Has no relevant financial relationship to disclose.
 Will not be discussing the off-label or investigational use of products
ACCREDITATION AND CREDIT DESIGNATION STATEMENTS
This activity has been planned and implemented in accordance with the accreditation requirements and
policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint
providership of Weill Cornell Medical College and _________________________. Weill Cornell
Medical College is accredited by the ACCME to provide continuing medical education for physicians.
Weill Cornell Medical College designates this live activity for a maximum of ____ AMA PRA
Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
EVALUATION
The CME Evaluation Form is included in your syllabus. Completed forms will be collected at the door
at the end of this activity. We encourage you to complete the Evaluation Form as this will allow us to
assess the degree to which the activity met its objectives. It will also guide the planning of future
activities and inform decisions about improving the educational program.
WCMC is accessible for individuals with disabilities or special needs. Participants with special needs
are requested to contact the Office of CME at 212-746-2631.