LETTER OF AGREEMENT
Terms, Conditions, and Purposes for Commercial Support *
between The University of Mississippi Medical Center (accredited provider)
and
__________________________________Joint Provider (if applicable)
_______________________ (commercial interest)
Form must be typed or printed legibly.
Title of CE Activity
Location
__________________________________________________
______________________ Date(s)
Name of Commercial Interest
_________________
__________________________________
Address______________________________________________________________________________
City, State, Zip________________________________________________________________________
Contact Person________________________________________________________________________
Telephone:
___Fax:
E-mail:
The above company wishes to provide support for the named continuing education activity by means of
(indicate which option):
1.
Unrestricted educational grant for support of the CE activity in the amount of $ ________________
2.
Restricted grant to reimburse expenses for:
A. Speaker(s) Name (s)________________________________
To include: 1) All Expenses___; 2) Travel Only____; 3) Consulting Fee Only____
$ ___________ (Consulting fee amount determined by the UMMC Course Director)
B. Support for catering functions (specify)__________________ in the amount of $_____________
Independence
1.
2.
Terms, Conditions, and Purposes
This activity is for scientific and educational purposes only and will not promote any specific
proprietary business interest of the Commercial Interest.
The Accredited Provider is responsible for all decisions regarding the identification of educational
needs, determination of educational objectives, selection and presentation of content, selection of all
persons and organizations that will be in a position to control the content of the CE, selection of
education methods, and the evaluation of the activity.
Appropriate Use of Commercial Support
3.
4.
5.
6.
The Accredited Provider will make all decisions regarding the disposition and disbursement of the
funds from the Commercial Interest.
The Commercial Interest will not require the Accredited Provider to accept advice or services
concerning teachers, authors, or participants or other educational matters, including content, as
conditions of receiving this grant.
All commercial support associated with this activity will be given with the full knowledge and
approval of the Accredited Provider. No other payments shall be given to the director of the activity,
planning committee members, teachers or authors, joint provider, or any others involved with the
supported activity.
The Accredited Provider will upon request, furnish the Commercial Interest documentation detailing
the receipt and expenditure of the commercial support.
Commercial Promotion
7.
8.
Product-promotion material or product-specific advertisement of any type is prohibited in or during
the CE activity. The juxtaposition of editorial and advertising material on the same products or
subjects is not allowed. Live or enduring promotional activities must be kept separate from the CE
activity. Promotional materials cannot be displayed or distributed in the education space immediately
before, during, or after a CE activity. Commercial Interests may not engage in sales or promotional
activities while in the space or place of the CE activity.
The Commercial Interest may not be the agent providing the CE activity to the learners.
Disclosure
9.
The Accredited Provider will acknowledge the source of support from the Commercial Interest in
program brochures, syllabi, and other program materials, and at the time of the activity. This
disclosure will not include the use of a trade name or a product-group message.
The Commercial Interest and The University of Mississippi Medical Center agree to abide by
all requirements of the Accreditation Council for Continuing Medical Education (ACCME)
Standards for Commercial Support of Continuing Medical Education American Nurses
Credentialing Center (ANCC) certified Mississippi Nurses Foundation (MNF) contact hours
for nursing credit, Accreditation Council for Pharmacy Education (ACPE) for pharmacy
credit, and American Dental Association Continuing Education Recognition Program (ADA
CERP) for dental credit.
* The ACCME defines a Commercial Interest as any entity producing, marketing, re-selling or distributing
healthcare goods or services consumed by, or used on, patients. The ACCME does not consider providers of
clinical services directly to patients to be commercial interest.
Name of Accredited Provider
University of Mississippi Medical Center
Tax ID Number
64-6008520
Contact Person
Phone Number
601-984-1300
Email Address
Fax Number
601-984-1309
Joint Provider (if applicable)
Contact Person
Phone Number
Tax ID Number
Email Address
Fax Number
Name of Commercial Interest
Address
City, State, Zip
Contact Person
Phone Number
Email Address
Fax Number
Agreed by Authorized Representatives
Commercial Interest
______________________________
Accredited Provider (UMMC)
Activity Director
______________________________
______________________________
______________________________
_____________________________
______________________________
Joint Provider (if applicable)
CE Department
______________________________
Signature and Date
Print Name
Title
___________________________________
Signature and Date
Signature and Date
Print Name
Title
Signature and Date
_____________________________
Elizabeth G. Franklin, PhD
_____________________________
Director, CHPE
Print Name
Title
Print Name
Title
___
Rev 05/12; 7/13