2023 WOEMA Disclosure Form

2023 WOEMA Disclosure Form

We are committed to presenting CME/CE activities that promote improvements or quality in health care and are developed free of the control of ineligible companies (formerly known as a commercial interest). It is our policy to ensure that our activities are balanced, independent, objective, scientific, and in compliance with regulatory requirements. Anyone who is in a position to control the content of a CME/CE presentation (course directors, faculty, planning committees, etc.) is expected to disclose all financial relationships with ineligible companies.* The information listed on this form will be used to assess and mitigate any potential conflict of interest you may have and will be disclosed to the audience of the CME/CE activity. Faculty/planners who refuse to disclose will be disqualified from participating in this CME/CE activity. If any questions please contact Shannon Cook at scook@lutinemangement.com.

First Name*

Last Name*

Email*

Title of Session (if applicable)

Role in Activity*

Individual’s prospective role(s) in education:

Identify the prospective role(s) that you have in the planning and delivery of this education (choose all that apply)

Select or enter value

Definition of an Ineligible Company:

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.)

Financial Relationships*

In the past 24 months, have you had a financial relationship of any amount with an ineligible company (see definition above)?

Select or enter value

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.

Enter Name of Ineligible Company & Relationship.

Example: ABC Company, Consultant

Has the Relationship Ended?

YES

2. Enter Name of Ineligible Company & Relationship

2. Has Relationship Ended?

YES

3. Enter Name of Ineligible Company & Relationship

3. Has the Relationship Ended?

YES

Additional Information

Please list any additional financial relationships, of any amount with an ineligible company with In the past 24 months below.

Attestation*

I attest that the above information is correct as of this date of submission.*

Please check for signature.

Agreement*

Typing my name in the space below I attest that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided on this form will be shared with learners prior to their engagement in this CME activity.

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