Continuing Medical Education Program
CME CONFLICT OF INTEREST DISCLOSURE
All individuals in a position to influence the content of a certified CME activity must disclose any relevant financial
relationship that might affect their independent involvement in the proposed CME activity. The intent of this policy is
to ensure that any potential conflict will be identified openly so that the activity participants may form their own
judgments about the presentation with the full disclosure of facts.
“Commercial entity” is any entity producing, marketing, re-selling, or distributing health care goods or services
consumed by, or used on, patients.
“Relevant financial relationship” is defined as a financial benefit that you, your spouse, or an immediate member of your
family has had within the past 12 months. This pertains to salaries, royalties, intellectual property rights, consulting
fees, honoraria, ownership interest or other financial benefits with pharmaceutical companies, biomedical device
manufacturers or other corporations whose products or services are related to the subject matter of the presentation
topic.
The Kettering Health Network (KHN) Continuing Medical Education (CME) Program tries to assure balance, scientific
rigor and validity in its sponsored CME events. To that end, planners and members are expected to disclose to the
program any conflict of interest. This disclosure will not prevent a planner or member from participation with the CME
Program.
ACTIVITY TITLE: ____________________________________________________________________________________
ACTIVITY DATE(S): _________________________________________________________________________________
PARTICIPANT’S NAME: _____________________________________________________________________________
ROLE:
Presenter
Planner of KHN event(s)
Liaison for KHN event(s)
Member of KHN Advisory Group
I do not have any relevant financial arrangements with one or more organizations that could be
perceived as a real or apparent conflict of interest in the context of this continuing medical education
activity.
I do have a financial interest/arrangement or affiliation with one or more organizations that could be
perceived as a real or apparent conflict of interest in the context of the subject of this continuing
medical education activity, as follows:
Relationship
Self
Family
Member
List Name(s) of Commercial Entity(ies)
Affiliation/Financial Interest
Grant Research Support
Consultant
Speaker’s Bureau
Major Stockholder
Other Financial/Material
Support
If you marked you do have a financial interest/arrangement or affiliation - please complete Page 2.
Your signature below attests to the accuracy of the information you have provided above and you have agreed to the
Planning Committee and Speaker Guidelines.
Signature: ______________________________________________________
Date: ________________________________________
Part B ATTESTATIONS (to assure CME Program compliance with the ACCME Standards of Commercial Support)
NAME: ________________________________________________________________________________________________
(PLEASE PRINT)
Please indicate your understanding of, and willingness to comply with each statement below. If you have questions
about your ability to comply, please contact the activity liaison person or the Program Coordinator as soon as possible.
Agree Disagree N/A
My above disclosures (if any) are all my commercial relationships relevant to this activity.
The content and information which I present will promote healthcare quality or
improvements, and will not promote specific products or procedures of a commercial
interest.
I understand that the KHN/CME Program will need to review the content of my
presentation prior to the activity, and I will provide specific items in advance as
requested.
For this activity, I have not and will not accept any honoraria, payments or
reimbursements in addition to that which has been agreed to directly with the KHN/CME
Program.
I understand that a KHN/CME representative may attend the activity to witness that my
presentation is not promotional and complies with the Standards for Commercial Support.
If I present clinical recommendations, they will be based on evidence accepted within the
profession of medicine as justification for indications and contraindications in patient
care.
All scientific research cited, reported or used in this activity that supports patient care
recommendations will conform to the generally accepted standards of experimental
design, data collection, and analysis, and not promote commercial interest.
When discussing specific products, I will use generic names when possible and will
compare evenly with similar products produced by other companies using generic names.
Trade names for products can be used if coupled with their generic names.
If I discuss any product use that is unapproved or off- label, I will disclose that the
product’s clinical use is not currently approved by the FDA for labeling or advertising.
If I have been an agent or a speaker for any commercial interest, promotional aspects of
related products will not be included in any way with this activity.
I have carefully read and considered each item in this form and have completed it to the best of my ability.
_________________________________________________________________
Signature
______________________________________________
Date
Your compliance with the ACCME Standards of Commercial Support is appreciated. Please return this
form as soon as possible to:
Kettering Health Network
Continuing Medical Education Program
3535 Southern Blvd, Kettering, OH 45429
Phone: (937) 395-8359 FAX: (937) 522-7436
Email: leejean.heller@khnetwork.org
Approved and Updated October 2015 by the CME Executives