Conflict of Interest Form

Authors, Co-authors, Presenters

Please complete the conflict of interest form below. This is a required document. Thank you.

Conflict of Interest Reporting Form

Postgraduate Institute for Medicine

CONFLICT OF INTEREST REPORTING FORM FOR FACULTY, PLANNERS, AND MANAGERS OF CME/CE ACTIVITIES

Because continuing medical, pharmacy, and nursing education (CME/CE) activities are conducted in the public interest, it is important to assure the public that education received by physicians and other health professionals through whom patient care decisions are made is conducted with the highest integrity, scientific objectivity, and in the absence of bias. A conflict of interest (COI) exists when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME/CE about the product or services of that commercial interest. The Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) each hold the provider of continuing education responsible for collecting information from its faculty, planners, and managers of CME/CE content and resolving those conflicts prior to the commencement of the CME/CE activity. The intent of the COI resolution process is to assure that provider, faculty, and planner financial relationships with commercial interests and resultant loyalties do not supersede the public interest in the design and delivery of CME/CE activities for the profession.


Criteria for Disclosure of Conflicts of Interest

Faculty, planners, and managers who affect the content of a CME/CE activity are required to disclose their own financial relationships, as well as relationships to products or devices their spouse/life partner have, with commercial interests related to the content of this CME/CE activity of any amount over the past 12 months ONLY.  A commercial interest is defined by the ACCME, ACPE, and ANCC as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Relationships with governmental agencies (e.g., the NIH) do not have to be disclosed. In addition, honoraria received from a CME/CE provider for serving as a CME/CE faculty member by you or your spouse/life partner, even though those funds may have been provided through an educational grant from a commercial interest, DO NOT HAVE TO BE DISCLOSED.


Project ID: 12779-LJ-37                         Activity: PAMA2018

Name(s) of Commercial Interest(s) Providing Support for this Activity (to date): N/A

Type of Financial Relationship WITHIN THE PAST 12 MONTHS ONLY

Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

* For Royalty and Patent Holder relationships, include product name along with Manufacturer/Company. Product information will be used only to identify degree of conflict and will NOT be disclosed to the learners; there is no need to report rights and royalties if they are fully assigned to another party.
Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

* For Royalty and Patent Holder relationships, include product name along with Manufacturer/Company. Product information will be used only to identify degree of conflict and will NOT be disclosed to the learners; there is no need to report rights and royalties if they are fully assigned to another party.
Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

** An accredited ACCME/ACPE/ANCC provider is NOT an agent for a manufacturer, whereas a company acting for a manufacturer in a promotional activity IS an agent.
Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

*** Only include research funds received directly from industry; grants to your institution are reportable only when you’re the person or named investigator on the grant.
Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

Indicate Applicable Manufacturer(s)/Company WITHIN THE PAST 12 MONTHS ONLY

By entering your name you agree that the information entered on this form is accurate.

* For Royalty and Patent Holder relationships, include product name along with Manufacturer/Company. Product information will be used only to identify degree of conflict and will NOT be disclosed to the learners; there is no need to report rights and royalties if they are fully assigned to another party.

** An accredited ACCME/ACPE/ANCC provider is NOT an agent for a manufacturer, whereas a company acting for a manufacturer in a promotional activity IS an agent.

*** Only include research funds received directly from industry; grants to your institution are reportable only when you’re the person or named investigator on the grant.

 

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