2025 Disclosure Form

To be Completed by Planner, Faculty, or Others Who May Control Educational Content:


As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. 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.


Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). 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. If you have questions, please reach out to Mandy Komenko at mkomenko@lutinemanagement.com


For any links to definitions in this form, right click on the link to open it in a new tab.

(Contact number for day of activity)

Phone

Please enter the title of the educational meeting or activity in which you are participating.

Please choose the name of the organization planning/holding the meeting from the below list.

Select or enter value
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Are you completing this disclosure as an author for an abstract/poster submission?*
Did your project relating to the abstract/poster receive financial support?*

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
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Nature of Financial Relationships

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.

Definition of 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.


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(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 below)?


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Standard 3: Identify, Mitigate, and Disclose Relevant Financial Relationships

(Check all that apply)


See below:

  • Include contracted research.
  • Individual stock 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.


Select
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Has the relationship ended?*

If the financial relationship existed during the last 24 months, but has now ended, please check "Yes." This will help the education staff determine if any mitigation steps need to be taken.

Do you have another financial relationship to disclose?*

(Check all that apply)

Select
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Has the relationship ended?*

If the financial relationship existed during the last 24 months, but has now ended, please check "Yes." This will help the education staff determine if any mitigation steps need to be taken.

Do you have another financial relationship to disclose?*

(Check all that apply)

Select
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Has the relationship ended?*

If the financial relationship existed during the last 24 months, but has now ended, please check "Yes." This will help the education staff determine if any mitigation steps need to be taken.

Do you have another financial relationship to disclose?*

(Check all that apply)

Select
Caret IconCaret symbol
Has the relationship ended?*

If the financial relationship existed during the last 24 months, but has now ended, please check "Yes." This will help the education staff determine if any mitigation steps need to be taken.

Do you have another financial relationship to disclose?*

(Check all that apply)

Select
Caret IconCaret symbol
Has the relationship ended?*

If the financial relationship existed during the last 24 months, but has now ended, please check "Yes." This will help the education staff determine if any mitigation steps need to be taken.

Do you have another financial relationship to disclose?*

Please describe any additional financial relationships of any amount with an ineligible company within the past 24 months below.

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


Please check for signature.

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