Form 11 C
Electronic Evaluation Information Process for Case Conference Instructions
Administrative Coordinator: The Highlighted information needs to be sent to the
CME office via email cme@ghs.org five (5) business days prior to the CME
Activity in order to have an evaluation/attestation posted in Survey Monkey.
Case Conference Name: __Example: Pediatric Tumor Board
Host Department: __Oncology _
Conf. Room Location: ST41 __________
Day, Wednesday Date: January 2, 2013; Time: _7:00am___________
Disclosures: The case conference participants have listed the following duality of interest
with regards to potential relevant financial relationships related to today’s case conference.
If all participants have disclosed none then then check none
_____ None
If one or more participants have disclosed something then list the disclosures below:
Example only ‘Jane Doe, MD Grant Research Support from Eli-Lilly, NIH, Sanofi-Aventis,
Pfizer. (this provides Name, affiliation and Commercial Interest/Organization all taken form
Summary of Disclosures)
Speaker/Moderator Disclosures
Affiliation
Name
Jane Doe, MD
(Financial Relationship, Grant/Research
Support, Consultant, Speaker's Bureau, Major
Stock Shareholder, Other Financial/Material
Support)
Grant Research Support
List type of patients to be discussed.
Pediatric Tumor
www.ghs.org/CME
Commercial
Interest/Organization
Eli-Lilly, NIH, Sanofi-Aventis,
Pfizer
Form 11 C
Electronic Evaluation Information for Case Conference send to cme@ghs.org
Case Conference Name: [Type text]
Host Department: [Type text]
Conf. Room Location: [Type text]
Day, [Type text]
Date: [Type text]
Time: [Type text]
Disclosures: The case conference participants have listed the following duality of interest
with regards to potential relevant financial relationships related to today’s case conference.
☐ None
If one or more participants have disclosed something then list the disclosures below:
Speaker/Moderator Disclosures
Affiliation
Name
(Financial Relationship, Grant/Research
Support, Consultant, Speaker's Bureau, Major
Stock Shareholder, Other Financial/Material
Support)
List type of patients to be discussed
[Type text]
8/13
Commercial
Interest/Organization