N E W Y O R K U N I V E R S I T Y P O S T -G R A D U A T E M E D I C A L S C H O O L
CONFLICT OF INTEREST / FULL DISCLOSURE FORM FOR INSTRUCTORS, PLANNERS AND MANAGERS
OF CONTINUING MEDICAL EDUCATION ACTIVITIES
CRITERIA FOR DISCLOSURE OF CONFLICTS OF INTEREST
In accordance with the requirements of the Accreditation Council for Continuing Medical Education (ACCME), instructors,
planners and managers involved in the development of the content of a CME activity are required to disclose to New York
University Post-Graduate Medical School (NYU-PGMS) financial relationships they or their spouse/partner have with ANY
commercial interests whose products or services might be discussed in this CME activity. Those relationships can be in any
amount and must have occurred in the past 12 months ONLY. A commercial interest is any entity producing, marketing,
re-selling, or distributing health care goods or services consumed by, or used on, patients.
In accordance with ACCME requirements, failure to provide disclosure information in a timely manner will result in the
disqualification of the potential instructor, course director, planner or manager from this activity.
Between now and the date of the activity, should there be any changes with respect to your potential conflicts of interest
(speakers agreements, grant support, etc.), please provide this information to the NYU-PGMS.
Name of CME Activity
Date of Activity
Name of Discloser
I am a/an:
instructor/speaker
moderator
independent reviewer
I intend to reference unlabeled/unapproved uses of drugs or products in my presentation. Please specify:
I have NO financial relationships with commercial interests to report. Please sign at bottom
OR
I or my spouse/partner have had the following types of financial relationships within the past 12 months
with the following commercial interests:
Type of Financial Relationship
Indicate Applicable Commercial Interest(s)
Salary
Royalty
Receipt of Intellectual Property Rights / Patent Holder
Consulting Fees (e.g., advisory boards)
Fees for Non-CME Services Received Directly from Commercial
Interest or their Agents1 (e.g., speakers’ bureaus)
Contracted Research
Ownership Interest (stocks, stock options, or other ownership
interest excluding diversified mutual funds)
Other (foundations, non-profits, etc.)
Does the CME content over which you have control contain any information about healthcare products or
services of any of the companies listed above?
Yes
No
Signature of Reporting Individual
1
If yes, please list which companies below and sign at bottom:
Date of Submission
An accredited ACCME provider is NOT an agent for a manufacturer, whereas a company acting for a manufacturer in a promotional activity IS an agent.
TERMS AND CONDITIONS FOR FACULTY
REGARDING COMMERCIAL SUPPORT
1. Disclosure
Speakers/authors/planners must complete and submit the Disclosure Statement located on the front side of this
document prior to the presentation, and ensure that the Disclosure Statement is complete and truthful to the best of the
respondent’s knowledge. Respondents are required to disclose any relevant financial relationships they may have
with commercial interests. Relationships with governmental agencies (e.g., the NIH) and organizations that do not
make or own FDA-regulated drugs or devices do not have to be disclosed. If you have received honoraria (or fee-forservice) or consulting funds from a CME provider, even though those funds may have been provided through an
educational grant from a commercial interest, YOU DO NOT HAVE TO DISCLOSE THOSE HONORARIA OR
FEES.
Failure to complete and return this disclosure will result in disqualification from participation in the planning
or presentation of this CME activity.
2. Fair Balance
Speakers/authors are required to prepare fair and balanced presentations that are objective and scientifically
rigorous.
3. Unlabeled and Unapproved Uses
Presentations that provide information in whole or in part related to non-FDA approved uses for drug products
and/or devices must clearly acknowledge the unlabeled indications or the investigational nature of their proposed
uses to the audience. Speakers/authors who plan to discuss non-FDA approved uses for commercial products
and/or devices must advise NYU-Post Graduate Medical School and the audience of their intent.
4. Use of Generic versus Trade Names
Presenters should use scientific or generic names when referring to products in their lectures or enduring
materials. Should it be necessary to use a trade name, then the trade names of all similar products or those within
a class should be used.
5. Commercial Supporter Influence
Faculty members are not permitted to receive any direct remuneration or gifts from the commercial supporter(s)
of this activity as it relates to this specific activity, nor should they seek or accept any input from a commercial
supporter, or from any other commercial interest, regarding the content of their presentations, as per the newly
modified policy on Independence adopted by the November 2007 meeting of the ACCME Executive Committee,
which states “CME providers can receive commercial support from industry. CME providers cannot
receive guidance, either nuanced or direct, on the content of the activity or on who should deliver that
content.”