DISCLOSURE OF FINANCIAL RELATIONSHIPS Step 1 of 2 50% CURRENT CONCEPTS INSTITUTE DISCLOSURE OF FINANCIAL RELATIONSHIPS HiddenMeeting ID(Required) HiddenMeeting(Required) Last Name(Required) First Name(Required) Role(Required)Select all that apply. Faculty Planning Committee Activity Director Administrative Coordinator 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 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.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.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.Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Do you need to add an additional Ineligible Company?(Required) Yes No Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No 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 Enter the Name of Ineligible Company(Required) Enter the Nature of Financial Relationship(Required) Has the Relationship Ended?(Required) Yes No Consent(Required) I agree that the information above is accurate to the best of my knowledge.
