One Medical Center Drive
Lebanon, NH 03756
Phone: (603) 650-3436
Fax: (603) 650-3434
DHMC CONFLICT of INTEREST (COI) / COI RESOLUTION and DISCLOSURE FORM
For Activity or Regularly Scheduled Series (RSS) Director(s), Planning Committee Member(s), Speaker(s), Author(s) or
Anyone in a Position to Control Content Offered During an Educational Activity
COI POLICY:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), and the American
Nurses' Credentialing Center's Commission on Accreditation (ANCC), Dartmouth-Hitchcock Medical Center must insure balance,
independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. Planning must be free
of the influence or control of a commercial entity, and promote improvements or quality in healthcare. All scientific research used to support
patient care recommendations must conform to generally accepted standards of experimental design, data collection, and analysis. All Activity
and RSS Director(s), Planning Committee Member(s), Speaker(s), Author(s) or Anyone in a Position to Control the Content are expected to
disclose to the audience any real or apparent conflicts of interest so that such conflicts can be resolved. Should the speaker’s presentation
include discussion of any off-labeled/investigational use of a commercial product, he/she is also required to disclose this to the activity
participants.
COI DEFINITION: Conflict of interest is created when individuals in a position to control the content* of the continuing education
program, or their spouses/partners, have a relevant relationship with a commercial interest (a) that benefits the individual in any financial
amount and (b) that has occurred within the past 12 months, therefore may bias their opinions and teachings. This may include 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 financial benefit. Financial benefits are usually associated with roles such as employment,
management position, independent contractor (including contracted research and clinical trials), consulting, speaking and teaching, membership
on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected.
Dartmouth-Hitchcock Medical Center (DHMC), Center for Continuing Education in the Health Science (CCEHS) providers
will identify, review and resolve all conflicts of interest that Activity or RSS Director(s), Planning Committee Member(s), Speaker(s),
Author(s) or Anyone in a Position to Control the Content disclose prior to an educational activity being delivered to learners.
ACTIVITY or RSS DIRECTOR, PLANNING COMMITTEE MEMBER, SPEAKER, AUTHOR OR
ANYONE IN A POSITION TO CONTROL CONTENT DISCLOSURE Form* (please circle appropriate
role(s)):
Title of Activity/Event/Program: _Neonatal APN Forum 2012
Date(s) of Program: May 30 – June 2, 2012_
Name (Please Print)
1.
2.
3.
a. NO, I and/or my spouse/legally recognized domestic partner have no financial interest/arrangements in any amount
within the past 12 months with one or more organization(s), which could be perceived as a real or apparent conflict of
interest and which would reasonably appear to influence my role as a potential course director, planning committee
member, speaker or author for any CME or CNE activity.
b. YES, I and/or my spouse/legally recognized domestic partner have a financial interest/arrangement in any amount
within the past 12 months with one or more organization(s), which could be perceived as a real or apparent conflict of
interest and which would reasonably appear to influence my role as a potential course director, planning committee
member, speaker or author for any CME or CNE activity. I have the following financial interests, arrangements, or
affiliations with the following corporate organizations:
Name of Company(ies)
GRANT/RESEARCH SUPPORT (External)
____________________________________________________
CONSULTANT
____________________________________________________
MAJOR STOCKHOLDER
____________________________________________________
SPEAKERS’ BUREAU (Specify therapeutic area)
____________________________________________________
OTHER FINANCIAL INTEREST
____________________________________________
I intend to discuss off-label or investigational use(s) of a product or device.
Name of Product(s)
Unlabeled/Off-label use of FDA-approved product
NO
YES _______________________________
Investigational Product (not FDA-approved)
NO
YES _______________________________
I attest that I am not receiving direct payments from a commercial entity with respect to this program/presentation.
If you answered YES to 1b. above, please forward a copy of your presentation slides as directed ASAP so that arrangements can be made for
the Activity or RSS Director, NCEC Member, CMEAC Member, or other authorized content expert to review your slides and resolve any
conflict well in advance of the lecture or activity
Signature ____________________________ Printed Name __________________________________ Date______________
(For electronic signatures, type your name here and then send electronically as enclosure. CME/CNE coordinator please attach a
copy of email to conflict of interest form that includes the sender and time/date stamp for documentation purposes.)
the DHMC/DMS Faculty CME Committee and NCEC, Revised 12/08,9/09,11/10