Disclosure of Financial Relationships Step 1 of 2 50% CURRENT CONCEPTS INSTITUTE DISCLOSURE OF FINANCIAL RELATIONSHIPS As a prospective planner or faculty, we would like to ask for your help in protecting our learning environment from industry influence. The ACCME Standards for Integrity and Independence in Accredited Continuing Education 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*. 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. Advertising, marketing, or communication firms whose clients are ineligible companies Bio-medical startups that have begun a governmental regulatory approval process Compounding pharmacies that manufacture proprietary compounds Device manufacturers or distributors Diagnostic labs that sell proprietary products Growers, distributors, manufacturers or sellers of medical foods and dietary supplements Manufacturers of health-related wearable products Pharmaceutical companies or distributors Pharmacy benefit managers Reagent manufacturers or sellers HiddenMeeting ID(Required) HiddenMeeting(Required) HiddenActivity Director First Name HiddenActivity Director Last Name HiddenActivity Director Email(Required) Last Name(Required) First Name(Required) Email(Required) Role(Required)Select all that apply. Planner (Activity Director, planning committee, staff involved in choosing topics, faculty, or content) Faculty/Presenter Author Other In the past 24 months, I have had financial relationships with ineligible companies.(Required) Yes No 1a. Enter the Name of Ineligible Company(Required) An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.1b. Enter the Nature of Financial Relationship(Required) Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.1c. Has the Relationship Ended?(Required) Yes No If the financial relationship existed during the last 24 months but has now ended, please enter yes in this column. This will help the education staff determine if any mitigation steps need to be taken.2. Do you need to add an additional Ineligible Company?(Required) Yes No 2a. Enter the Name of Ineligible Company(Required) 2b. Enter the Nature of Financial Relationship(Required) 2c. Has the Relationship Ended?(Required) Yes No 3. Do you need to add an additional Ineligible Company?(Required) Yes No 3a. Enter the Name of Ineligible Company(Required) 3b. Enter the Nature of Financial Relationship(Required) 3c. Has the Relationship Ended?(Required) Yes No 4. Do you need to add an additional Ineligible Company?(Required) Yes No 4a. Enter the Name of Ineligible Company(Required) 4b. Enter the Nature of Financial Relationship(Required) 4c. Has the Relationship Ended?(Required) Yes No 5. Do you need to add an additional Ineligible Company?(Required) Yes No 5a. Enter the Name of Ineligible Company(Required) 5b. Enter the Nature of Financial Relationship(Required) 5c. Has the Relationship Ended?(Required) Yes No 6. Do you need to add an additional Ineligible Company?(Required) Yes No 6a. Enter the Name of Ineligible Company(Required) 6b. Enter the Nature of Financial Relationship(Required) 6c. Has the Relationship Ended?(Required) Yes No 7. Do you need to add an additional Ineligible Company?(Required) Yes No 7a. Enter the Name of Ineligible Company(Required) 7b. Enter the Nature of Financial Relationship(Required) 7c. Has the Relationship Ended?(Required) Yes No 8. Do you need to add an additional Ineligible Company?(Required) Yes No 8a. Enter the Name of Ineligible Company(Required) 8b. Enter the Nature of Financial Relationship(Required) 8c. Has the Relationship Ended?(Required) Yes No 9. Do you need to add an additional Ineligible Company?(Required) Yes No 9a. Enter the Name of Ineligible Company(Required) 9b. Enter the Nature of Financial Relationship(Required) 9c. Has the Relationship Ended?(Required) Yes No 10. Do you need to add an additional Ineligible Company?(Required)If you have more than 10 ineligible companies to disclose, please return to the original email, follow the link again, and input the remaining companies on a second form. Yes No 10a. Enter the Name of Ineligible Company(Required) 10b. Enter the Nature of Financial Relationship(Required) 10c. Has the Relationship Ended?(Required) Yes No Verification(Required) I attest that the above information is true and accurate.
