East Tennessee State University
James H Quillen College of Medicine
Office of Continuing Medical Education
Upon completion of this form and obtaining the requisite signatures, you may fax this
document to us at 423 439 8040. If you have any questions, call us at 423 439 8081, or email us
at dougherty@etsu.edu. Your application will not be presented to the Advisory Board without
the required signatures.
Required Signatures
Activity Directors are required to provide the Office of CME the following information and
signatures prior to the program being presented to the Advisory Board:
1. The Activity Director’s Conflict of Interest Disclosure embodied in Section One below.
2. The Activity Director Responsibilities in Section Two that follows. The Activity Director’s
Signature must also be counter signed by the appropriate Academic Chair, or Healthcare
Organization’s appropriate Executive Officer
Please complete the following information so we can match this document to your program application
Title of CME Activity:
Date of CME Activity:
Activity Director Name
Section One: Activity Director’s Conflict of Interest Disclosurei
In the past 12 months have you, your spouse, or an immediate member of your family had a financial
interest/arrangementii or affiliation with one or more Commercial Organizationsiii that could be
perceived as a real or apparent conflict of interest?
Type of Relationship
Grant/Research Support
Other Remuneration (Speaker’s Bureau, Honoraria,
Travel Expenses, Etc.)
Consultant Fees, Salary
Major Stock / Shareholder (Not Mutual Funds)
Advisory Board
Ownership, Partnership
Do you anticipate discussing the unapproved or
investigative use of a commercial product or device
during this activity?
1
List Organization Name(s) For Each “YES”
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2009
Section Two: Activity Director Responsibilities
It is the obligation of a Continuing Medical Education (CME) Activity Director, with assistance from the
Office of CME at East Tennessee State University, to design, develop and implement an educational
program that is in the best interest of the CME learner and which improves competence, performance
or patient outcomes. Continuing Medical Education Activities at ETSU and those jointly sponsored by
ETSU, are planned for scientific and educational purposes only and may not be used to promote the
product or service of any commercial interest.
Activity Director Responsibilities: With Support of the CME Educational Planner, the Activity Director
has the following responsibilities:
 Select and recruit the Planning Committeeiv
 Disclose any potential conflict of interestv
 Submit and sign application
 Prior to the conference, resolve any speaker potential Conflict of Interest through peer review.vi
 At the activity, serve as moderator, as well as assist when appropriate with introducing
speakers, announcing disclosure information and facilitating discussion.
Activity Director and Planning Committee Responsibilities
 Identify and secure speakersvii
 Establish speaker honorariaviii, assuring it meets ETSU policy.ix
 Assist Office of CME in identifying opportunities for Commercial Supportx
 Review the outcomes of the activity, and determine the extent to which objectives were met
Activity Director Required Signature
I have reviewed my responsibilities, and agree to support them in the development and
implementation of this activity. Further, I have completed the above Conflict of Interest Disclosure and
my signature below attests to what I have provided.
Activity Director Signature
Please Print Name
Date:
Academic Chair or Hospital Executive Required Signature
I have reviewed this application and authorize the above named Activity Director to conduct this
continuing medical education activity on behalf of this Department / Organization
Academic Chair or Hospital
Executive Signature:
Please Print Name
Date:
End of document.
You do not need to return the attached footnotes.
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2009
Conflict of Interest Disclosure Policy: This Disclosure Policy is in keeping with the requirements of the Standards for Commercial Support of the
Accreditation Council for Continuing Medical Education.
As an ACCME accredited sponsor, the Office of Continuing Medical Education at East Tennessee State University, Quillen College of Medicine
subscribes to the ACCME Standards for Commercial Support of CME regarding responsibility for content, quality, and scientific integrity of all
activities certified for credit. Presenters must give a balanced view of therapeutic options. Use of generic names for products is preferred.
When trade names are used, those of several companies should be used, rather than only that of a single supporting company.
The Office of CME at East Tennessee State University's Quillen College of Medicine acknowledges the valuable contributions made by industry to
the development and provision of continuing medical education activities, products, and services. The Office of CME desires to ensure that its
activities adhere to the highest standards of educational and ethical quality. This further includes a commitment by the speaker to disclose all
meaningful relationships with commercial entities whether or not the activity receives commercial support.
All CME speakers are required to provide the Office of CME with a signed disclosure of the existence within the prior 12 months of this CME
activity of any financial interest or other relationship they, or immediate members of their family, may have with the manufacturer of any
commercial products discussed in an educational activity. The information must be provided in a timely fashion so that it can be included in
announcements, syllabi, or other program printed materials. When the information is not available in that manner, an announcement of those
relationships shall be made from the podium prior to the presentation.
When a Conflict of Interest is disclosed by a speaker, their presentation will be peer reviewed within ETSU, to ensure objectivity, balance, and
indication of evidence-based material, free of commercial bias, prior to the date of the conference.
ii
Financial relationships are those relationships in which the individual 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 financial benefit. Financial benefits are usually associated with roles such as employment, 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. ACCME considers relationships of the person involved in the CME
activity to include financial relationships of a spouse or partner
iii
A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,
patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests.
iv
Prior to submitting a CME Program Application form, the Activity Director is responsible for selecting members of a planning committee. This
committee, ideally comprised of representatives from groups identified in the conference’s target audience, is designed to assist the Program
Director in the identification and selection of topics and speakers, as well as aid in overall planning of the conference.
v
The Activity Director and all Planning Committee members are required to complete and submit a Disclosure Statement to the Office of CME
along with the CME Program Application form. The Disclosure Statement identifies any possible Conflict of Interest that these individuals may
have had during the prior 12 month period.
vi
The Activity Director will take responsibility for addressing and attempting to resolve the COI. It is important to note that the Office of CME
has a process and policy for removing a potential Conflict of Interest, and that the CME Planner will assist with this process.
vii
Speaker selection will be based on knowledge and experience in the selected topic area regardless of the possibility or availability of
commercial support. Initial discussions with possible speakers should convey the expectation that they are responsible for presenting a
balanced and unbiased presentation, and should reflect the most current and up-to-date evidence-based information on the selected topic.
viii
It is the Activity Director and planning committee members’ responsibility to determine appropriate speaker honoraria, based on the
conference budget and in accordance with the ETSU College of Medicine Honoraria policy.
ix
ETSU Honoraria Policy:
 The credentials of the CME speakers, expertise, as well as time and distance away from home should be considerations when deciding
upon the level of honorarium.
 The honorarium amount is determined by the Activity Director of the CME activity and it not associated with either the level of
commercial support provided or to specific requests of the commercial interest. Usual and customary honoraria for visiting faculty CME
activities at East Tennessee State University ranges between $250 and $1,500 per presentation in accordance with ETSU COM policy.
 Honorarium, for CME speakers, beyond $1,500 must be approved by the CME Advisory Committee. Activity Directors will submit a brief
justification, in writing, to the CME Advisory Committee for their review. The justification would include the considerations listed above.
Any honorarium above $1,500 requires CME Advisory Committee approval before a CME speaker contract will be issued.
 ETSU faculty will not receive an honorarium for internal COM/ETSU regularly scheduled educational activities (whether CME credit is
granted or not) such as grand rounds, journal clubs, and other CME series conferences, but may be compensated for presentations at a
special multi-hour conferences.
x
If applicable, the Activity Director and Planning Committee members will assist the CME planner in identifying potential sources of commercial
support based on conference objectives, topics, and proposed curriculum. The CME Planner will complete all paperwork/applications required
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2009
to meet the requirements of the individual commercial supporters to secure the unrestricted educational funds which will help support the
educational activity. It is important to note than ONLY the Office of CME can solicit and request support from a commercial entity.
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2009