Katrina Wolford, Continuing Medical Education
Akron Children’s Hospital
One Perkins Square, Akron, OH 44308
Office: 330-543-8407
RETURN FORM TO:
Kara Strittmatter at kara@umdf.org
Or by Fax: 740-417-4367
Full Disclosure for CME Activities
CME Activity
Mitochondrial Medicine 2016: Seattle
Presentation Title
Name
Date of Presentation
Role in CME Activity: ____ Planning Committee
June 15-18, 2016
____ Faculty/Presenter/Moderator
It is the policy of Akron Children’s Hospital Continuing Medical Education Department to ensure balance, independence, objectivity, and scientific rigor in all
of its individually sponsored or jointly sponsored educational activities.
We use the following definitions to determine commercial interest and financial relationships. Please proceed to signature #1 if you have nothing to disclose and signature #2
to disclose your financial relationships.
Commercial Interest: Any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care
related companies.
Financial Relationships: Those relationships in which the individual (or spouse/partner) benefits by receiving a salary, royalty, intellectual property rights, consulting fee,
honoraria, ownership interest (e.g. stocks, stock options or other ownership interest, excluding diversified mutual funds), or other management position, independent
contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities
from which remuneration is received or expected.
PLEASE COMPLETE AND SIGN EITHER NUMBER 1 OR 2
1. NEITHER I, the undersigned, NOR my spouse/partner, HAVE/HAS had financial or other relationships with any commercial
interest (during the past 12 months).
Signature
Date
1/1/2016
2. Within the past 12 months I, the undersigned, or my spouse/partner HAVE/HAS had a financial arrangement or affiliation with the
organizations or companies noted below.
Addendum: Akron Children’s Hospital, as part of its accreditation by the Ohio State Medical Association (OSMA), is required to “resolve” any potential conflicts of interest
prior to the educational activity. Therefore, in light of the relationships/affiliations you designate, WE ASK THAT YOU ATTEST:
a. that these relationships/affiliations will not bias or otherwise influence your involvement in the CME activity;
b. that practice recommendations given relevant to the companies with whom you have relationships/affiliations will be supported by best available evidence or, absent
evidence, will be consistent with generally accepted medical practice;
c. and, that all reasonable clinical alternatives will be discussed when making practice recommendations.
AFFILIATION/FINANCIAL INTEREST
COMMERCIAL INTEREST/ORGANIZATION
Grant/Research Support
Consultant
Speaker’s Bureau
Stock Shareholder
Other Financial or Material Support
Signature
Date
1/1/2016
FOR CME OFFICE USE ONLY
RESOLUTION OF CONFLICT OF INTEREST
Through review, it has been determined there is no conflict of interest with regard to this activity
All financial disclosures have been reviewed and will be disclosed
Presentation submitted in advance to allow for adequate peer review
An alternative speaker for this topic has been recommended to the planning committee for consideration
Conflict of Interest has not been resolved
NOTES:
Additional information may be requested to resolve conflict of interest. Disclosure will be made to participants prior to educational activity.
Reviewed by:
Date: