Continuing Education Disclosure Form

In support of ACCME Accreditation Standard 3: Identify, Mitigate & Disclose Relevant Financial Relationships

Disclosure Forms

A person only needs 1 Disclosure Forms in the database, one form can be used for multiple credit applications

Disclosure forms last for 2 years

Check the CE Disclosure Dashboard to view/verify active disclosures

First Name

If you use a middle name or initial, please include it after you enter your first name.

Last Name

Occupation

In the past 24 months, I have had financial relationships 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.

Yes

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.

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