HAWAII CONSORTIUM FOR CONTINUING MEDICAL EDUCATION
Disclosure Declaration and Attestation Form
Please print or type:
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Name:
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Role(s):(e.g. speaker, moderator, panel, author,
planning committee, other - please describe)
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CME Activity:
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Date(s):
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Presentation Title(s):
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♦CONFLICT OF INTEREST POLICY: It is the policy of the Hawaii Consortium for Continuing Medical Education (HCCME) to ensure balance, independence, objectivity, and scientific rigor in all its individually sponsored educational activities. Individuals who may influence content, such as planners, speakers, authors or others must disclose relevant financial relationships with commercial interests that pertain to this specific activity. (See reverse for glossary of terms) Should it be determined that a conflict of interest exists as a result of a financial relationship you have disclosed, the conflict of interest must be resolved prior to the activity. If you refuse to provide disclosure information, you will be disqualified from being a part of the planning or implementation of this CME activity. All disclosed relevant commercial interests will be provided to meeting attendees prior to your presentation. It is also recommended that speakers verbally state such relationships when appropriate during their presentation.
♦ UNLABELED USES OF PRODUCTS: Speakers are also required to disclose to the audience when a product discussed is not labeled for the use under discussion or that the product is still investigational.
1) Will your presentation include discussion of any product not labeled for the use under?
Yes No discussion or any product that is still investigational?
⇒ ⇒ ⇒ Proceed to question 2.
2) Within the past 12 months, have you or your spouse/partner had relevant financial
Yes No relationships or affiliations with commercial interests?
⇒ ⇒ ⇒ If answer to question 2 is No, please complete form by signing in box below.
⇒ ⇒ ⇒ If answer to question 2 is Yes, please continue.
Complete disclosure section below and sign on page 2.
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Type of Financial Relationship
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List Name of Commercial Interest(s)
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Grant/Research Support
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Consultant
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Speakers' Bureau
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Stock Shareholder
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Advisory Committee/Board
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Patent holder
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Other Financial or Material Support
(please describe)
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In light of the relationships/affiliations I have listed, I ATTEST to all of the following:
- • that these relationships/affiliations will not bias or otherwise influence my involvement in the program;
- • that practice recommendations given relevant to the companies with whom I have relationships/affiliations will be supported by the best available evidence or, absent evidence, will be consistent with generally accepted medical practice;
- • and, that all reasonable clinical alternatives will be discussed when making practice recommendations.
GLOSSARY OF TERMS
New (August 2007) Commercial Interest
The ACCME defines a 'commercial interest' as "any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients." (Effective immediately.)
The ACCME does not consider providers of clinical service directly to patients to be commercial interests.
A commercial interest is not eligible for ACCME accreditation. Within the context of this definition and limitation, the ACCME considers the following types of organizations to be eligible for accreditation and free to control the content of CME.
501-C Non-profit organizations (Note: ACCME screens 501c organizations for eligibility. Those that advocate for 'commercial interests' as a 501c organization are not eligible for accreditation in the ACCME system. They cannot serve in the role of joint sponsor, but they can be a commercial support.)
Government organizations
Non-health care related companies
Liability insurance providers
Health insurance providers
Group medical practices
For-profit hospitals
For-profit rehabilitation centers
For-profit nursing homes.
Financial relationships
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.
'Contracted research' includes research funding where the institution gets the grant and manages the funds and the person is the principal or named investigator on the grant.
Relevant financial relationships
ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines "relevant financial relationships" as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.
Conflict of Interest
Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.