VUMC ANCC Provider Unit Financial Disclosure Screening

As an accredited provider, we require your assistance to comply with accreditation guidelines and help us create high-quality accredited continuing education that is independent of industry influence. To participate in this educational activity, all individuals who have the ability to influence and/or control the content of this activity must disclose all financial relationships, within the last 24 months, with all companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.


For more information, please refer to the Standards for Integrity and Independence in Accredited Continuing Education

Please include all credentials: degrees, licensure, and certifications: e.g., MSN, RN, NPD-BC)

Please provide the best phone number to reach you directly. This phone number will only be used if/when mitigation is required for a relevant financial relationship(s) described below.

Phone

Financial Relationships

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (definition: an ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.).


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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.


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.


For specific examples of ineligible companies visit www.accme.org/standards

In the past 24 months, have you had a financial relationship with an ineligible company (defined above)?*

If unsure, select yes and complete the remaining questions.

Relevant Financial Relationship #1

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #2

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #3

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #4

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #5

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #6

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 www.accme.org/standards


Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #7

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #8

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #9

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #10

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #11

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #12

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 www.accme.org/standards



Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.


Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #13

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #14

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Relevant Financial Relationship #15

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 www.accme.org/standards

Examples 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST 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 select yes. This will help the education staff determine if any mitigation steps need to be taken.

Is the content of your presentation related to products, services, or devices from this ineligible company?*
Will the product, service, or device be discussed during this continuing education activity?*
Do you have another financial relationship to disclose?*

Attestation

I have disclosed all relevant financial relationships and understand this information will be disclosed to learners.*
The content and/or presentation of the information with which I am involved will promote quality or improvements in health care and will not promote a specific proprietary business interest of an ineligible company as defined by the Standards for Integrity and Independence in Accredited Continuing Education. Content for this activity, including any presentation of therapeutic options, will be balanced, evidence-based and commercially unbiased.*
I understand that my presentation/content may need to be reviewed prior to this activity, and I will provide educational content and resources in advance as requested.*
If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to will conform to the generally accepted standard of experimental design, data collection and analysis.*
If I discuss specific drugs, devices or services, I will use generic names to the extent possible. If using a trade name is unavoidable, I will provide trade names from several companies when possible, and not highlight a specific company product in any way.*

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