Disclosure CCI Current Concepts Institute Disclosure Step 1 of 2 50% CURRENT CONCEPTS INSTITUTE DISCLOSURE OF FINANCIAL RELATIONSHIPSHiddenMeeting ID HiddenMeeting Last Name(Required) First Name(Required) Email(Required) Role(Required) Faculty Planning Committee Activity Director Administrative Coordinator Other As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education. An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Standards for Integrity and Independence in Accredited Continuing Education In the past 24 months, I have had financial relationships with ineligible companies.(Required) Yes No Enter Financial Relationships with Ineligible CompaniesTo add ineligible company, select “Add Entry” for each company. Enter the Name of Ineligible Company Enter the Nature of Financial Relationship Has the Relationship Ended? Row ID Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Consent I agree that the information above is accurate to the best of my knowledge.