GLOSSARY
Disclosure of Relevant Financial Relationships
Name & Credentials:
Date of Activity:
Job Title:
Employer:
E-mail address:
Best Telephone:
Your role: Planner
Faculty
Reviewer/Other
Commercial Interest
A “commercial interest” is defined as any entity
producing, marketing, re-selling, or distributing
health care goods or services consumed by or
used on patients. Entities providing clinical
services directly to patients are not considered
to be commercial interests. A commercial
interest is not eligible for ACCME / ACPE /
ANCC accreditation.
Expertise (please describe your expertise and training specific to this educational activity):
Financial Relationship
Financial relationships are those relationships
in which the individual benefits by receiving a
salary, royalty, intellectual property rights,
Presentation Title(s):
consulting fee, honoraria, ownership interest
Please note that each talk needs a disclosure slide and topic objectives included at the beginning of the presentation. The disclosure slide
(e.g., stocks, stock options or other ownership
should be the second slide; objectives on the third slide of their presentation. A disclosure slide template will be provided.
interest, excluding diversified mutual funds), or
other financial benefit. Financial benefits are
Per ACCME/ACPE/ANCC (CNA) requirements, persons who fail to sign and return this form are not eligible to usually associated with roles such as
employment, management position,
be involved with this activity.
independent contractor (including contracted
research), consulting, speaking and teaching,
#1: Disclosure of Relevant Financial Relationships –
List the names of proprietary entities producing health care goods/services, with the exemption of non-profit or government organizations and non-health care membership on advisory committees or
related companies, with which you/your spouse/partner have, or have had, a relevant financial relationship within the past 12 months.
review panels, board membership, and other
activities from which remuneration is received,
or expected. Financial relationships of
With respect to this educational activity (check one):
spouses/partners are included in this
No, I do not have a relevant financial relationship. (Skip to #2 below.)
definition.
Title of Conference or Series:
Yes, I do have a relevant financial relationship. Provide information below:
Nature of Relevant Financial Relationship
(choose all that apply)
Name of Company(s)
Speaker’s Bureau
Grant/Research Support
Consultant
Stock Shareholder (directly purchased)
Honoraria
Full-time/part-time Employee
Other (explain):
#2: Disclosure of Off-Label and/or Investigational Uses –
If, at any time, during my education activity I discuss an off-label/investigative (unapproved) use of a commercial product/device,
I understand that I must provide disclosure of that intent.
No, I do not intend to discuss an off-label/investigative use of a commercial product/device. (Skip to #3 below.)
Yes, I do intend to discuss off-label/investigative uses(s) of the following commercial product(s)/device(s):
#3: Presentation(s) Content: Faculty Responsibility –
D:\99123263.doc
Relevant Financial Relationship
Relevant Financial Relationships with
commercial interests include the 12-month
period preceding the time that the individual is
being asked to assume a role controlling
content of the CME/ACPE/CNE activity. A
minimal dollar amount for relationships to be
significant has not been set. Inherent in any
amount is the incentive to maintain or increase
the value of the relationship. “Relevant’
financial relationships” are defined as financial
relationships in any amount occurring within
the past 12 months that create a conflict of
interest. After you submit the completed
disclosure form, it is your responsibility to
inform the CE providers if the status of
your financial relationship changes prior to
your presentation.
Off-Label Use and/or Investigational Uses
FDA Statement
Some drugs or medical devices demonstrated
have not been cleared by the FDA or have
been cleared by the FDA for specific purposes
only. The FDA has stated that it is the
responsibility of the physician to determine the
FDA clearance status of each drug or medical
devices he or she wishes to use in clinical
practice.
“Off label” uses of a drug or medical device
may be described in CME activities so long as
the “off label” use of the drug or medical
device is also specifically disclosed (i.e. it must
be disclosed that the FDA has not cleared the
drug or device for the described purpose). Any
drug or medical device is being used “off label”
if the described use is not set forth on the
product’s approval label.
 The Presenter warrants that nothing in their presentation is libelous or will infringe the rights of any third party. Presenter also warrants that for
any third party materials incorporated into their presentation, they have obtained all necessary permission from the copyright owner of such
material. Upon request Presenter agrees to furnish copies of said permission(s) to the CME/CNE/CPE provider(s). The Presenter is responsible
for all fees, royalties, and other charges for the use of such materials. The Presenter shall indemnify the CME/CNE/CPE provider(s) for all
damages, costs and expenses, including attorneys' fees, incurred by CME/CNE/CPE provider(s) as a result of a violation of this paragraph.
 Presentations must give a balanced view of therapeutic options and utilize best available evidence. Use of generic drug names contributes to
impartiality. Also, if your educational material or content includes trade names then trade names from several companies should be used where
available, not just trade names from a single company.


All information disclosed will be shared with the audience either verbally, on program handouts, advertising and/or audiovisual presentation.
After you submit the completed disclosure form, it is your responsibility to inform the CME/CNE/CPE provider(s) if the status of your financial
relationship changes prior to your presentation.
By checking this box, I attest that the completed information is accurate. Please accept this as my signature.
Printed Name: ___________________________________
Date: ____________________
Return form to:
Dena Graves
Continuing Education Administrative Assistant III
College of Nursing Office of Continuing Education and Professional Development
13120 E. 19th Ave., C288-11
Aurora, CO 80045
Phone: 303-724-6883
Fax: 303-724-1744
dena.graves@ucdenver.edu
Planner, Reviewer, Faculty and Content Specialist Conflict of Interest Statement
The University of Colorado (CU) School of Medicine (SOM) is accredited by the Accreditation Council for Continuing Medical
Education (ACCME). The CU College of Nursing (CON) is an approved provider of continuing nursing education by the Colorado Nurses
Association, an accredited approved by the American Nurses Credentialing Center’s Commission on Accreditation. The CU Skaggs
School of Pharmacy and Pharmaceutical Sciences (SSPPS) is accredited by Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education. As such, we have made the choice to meet the ACCME, CNA, ANCC and ACPE expectations for our
practice of continuing medical, nursing, and pharmacy education. Our accreditation/providership is important to us. We look forward to
working together to provide CME/CNE/CPE of the highest standard.
The CU SOM and CON and SSPPS have implemented a process where everyone who is in a position to control the content of an
education activity has disclosed to us all relevant relationships (financial or otherwise) with any commercial interest. Having an interest in
an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to
the start of the activity. In addition, should it be determined that a conflict of interest exists as a result of a relationship, this will need to be
resolved prior to the activity. This information is necessary in order to move to the next steps in planning this CME/CNE/CPE activity.
To ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure
indicating whether they and/or their immediate family (includes spouse/partner) have any relationships with pharmaceutical
companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas.
All planners, faculty, content specialists and feedback specialists participating in CE activities must disclose to the audience information
listed above. If you refuse to disclose relevant relationships, you will be disqualified from being a part of the planning and implementation
of this CME/CNE/CPE activity.
*************FOR OFFICE USE ONLY*****************
How will any conflict of interest be resolved?
____Discussed this conflict with the individual who is now aware of and agrees to our policy.
____Presenter has signed a statement that says s/he will present information fairly and without bias.
____CME/CNE/CPE Planner or designee will monitor session to ensure conflict does not arise.
____Not applicable, no conflict of interest
____Revisions made to content based on review by an impartial content expert.
____Other. Describe:
D:\99123263.doc