Disclosure Form

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 to the Continuing Education (CE) Department at cmedepartment@childrens.harvard.edu by the deadline outlined by the course directors/planners/coordinators or CE staff.

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 cmedepartment@childrens.harvard.edu.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies. 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. 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.