DisclosureForm

Name(Required)
Education Event Information
Individual's prospective role(s) in education(Required)
Identify the prospective role(s) that you have in the planning and delivery of this education (choose all that apply)

Relationships

As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form below and return it Taryn Daigle by submitting this form. 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. Thank you for your diligence and assistance. If you have questions, please contact us at (337) 945-9209.

To be completed by Planner, Faculty, or Others Who May Control Educational Content

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.
Enter the Name of Ineligible Company(s)
An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.
Enter the Nature of Financial Relationship
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?
If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken
No Relationships
By filling in the date below and submitting the form, I attest that the above information is correct as of this date of submission.
MM slash DD slash YYYY

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