Office of Continuing Medical Education
233 Richmond Street, Box G-R156
Providence RI 02912
January 29, 2016
We kindly ask that you complete the attached Disclosure of Relevant Financial Relationships Form and
return it with a current CV or Bio to the Brown Office of Continuing Medical Education (CME) no later
than February 19th. This information is necessary in order to finalize the program for the CME
accreditation process and marketing purposes.
We would like to take this opportunity to inform you of the following Standards of Practice in
Continuing Medical Education. As a provider accredited by the Accreditation Council for Continuing
Medical Education (ACCME), the Alpert Medical School of Brown University must ensure balance,
independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored
educational activities. Any individual being considered to participate in a sponsored activity who is in a
position to control the content is required to disclose all relevant financial relationships with commercial
interests. The intent of this disclosure is to aid the CME Office in determining: 1) if a conflict of interest
exists; and, if so, 2) if that conflict can be resolved. All such information disclosed by everyone appointed
to participate in the CME activity will be disclosed to the CME activity participants. Refusal to disclose
prohibits participation.
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Content Validation: Specifically, all recommendations involving clinical medicine in a CME activity
must be based on evidence that is accepted within the profession of medicine as adequate
justification for their indications and contraindications in the care of patients. All scientific research
referred to, reported or used in CME in support or justification of a patient care recommendation
must conform to the generally accepted standards of experimental design, data collection and
analysis.
Safeguards Against Commercial Bias: The content or format of CME activities and related materials
will promote improvements or quality in healthcare and not a specific proprietary business interest
of a commercial interest. The Brown CME Office employs several strategies to ensure the absence of
commercial bias and you are integral to their successful implementation. Educational materials that
are a part of this activity, such as slides, abstracts, and handouts, cannot contain any advertising,
trade names, or product-group messages. Should your presentation include discussion of
unlabeled/investigational use of a commercial product, you are required to disclose this to the
participants.
Thank you in advance for your cooperation. If you have any questions or concerns regarding this
request, please contact:
Maria Sullivan
Director, Office of Continuing Medical Education
Email: Maria_Sullivan@Brown.edu Ph. 401-863-1208
Office of Continuing Medical Education
233 Richmond Street, Box G-R156
Providence RI 02912
Faculty Disclosure of Relevant Financial Relationships
Northeast Group on Educational Affairs 2016 Annual Meeting – April 8-9, 2016
Presentation Title:
Presenter Name:
Check all
that apply:
Presenter:
Course Director
Author
Reviewer
Moderator
Planning Committee
As a provider accredited by the ACCME, the Alpert Medical School of Brown University must ensure balance, independence,
objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. Any individual being
considered to participate in a sponsored activity who is in a position to control the content is required to disclose all relevant financial
relationships with commercial interests. The intent of this disclosure is to aid the Continuing Medical Education Office in
determining: 1) if a conflict of interest exists; and, if so, 2) if that conflict can be resolved. All such information disclosed by everyone
appointed to participate in the CME activity will be disclosed to the CME activity participants. Refusal to disclose prohibits
participation.
* 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.
** A Commercial Interest is any proprietary entity producing, marketing, reselling, or distributing health care goods or services, consumed
by, or used on, patients, with the exemption of government organizations and providers of clinical service.
I. Do you, your spouse or legally recognized domestic partner currently (within the past 12 months) have a relevant financial interest with any
commercial interests?
YES
NO
II. If Yes, please complete the following. (if additional space is needed, please attach):
Nature of Financial Relationship
Commercial Interest(s)
Grant/
Research
Support
Consultant
Major
Stockholder
Speakers
Bureau
Other
(Be Specific)
1.
I
Spouse/Partner
2.
I
Spouse/Partner
3.
I
Spouse/Partner
III. Content Validation: I attest that my presentation will be evidence based or based on scientific methods generally accepted by the medical
community and presented in a balanced, objective manner. (please initial) _______________
IV. Commercial Bias: The Commercial Support Standards require that your presentation be free of commercial bias and that any
information regarding commercial products/services be based on scientific methods generally accepted by the medical community.
Presentations must give a balanced view of therapeutic options. When discussing therapeutic options, we request that only generic
names be used. If it is necessary to use a trade name, then those of several companies where available must be used.
V. Unlabeled/Investigational Uses: Should your presentation include discussion of unlabeled/investigational use of a commercial product, you
are required to disclose this to the participants. Will your presentation discuss unlabeled/investigational uses of a commercial product?
YES
NO
Signature: ____________________________________________
Date:_______________________________
Return this form to the Brown CME Office no later than February 19 th
Fax: 401-863-2202 or Email: CME@Brown.edu