Disclosure Statement for Education Planning Faculty

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.

Provider Activity ID

RSS-xxx, LC-xxx, EM-xxx, BOL-xxx, P/QI-xxx) If you do not know your Provider Activity ID, please reach out to the coordinator of this event.

Activity Title

Prospective Role(s) in Education

Please select all your roles that apply to this event:

Please check each statement to indicate your agreement. I agree to:

Disclose all financial relationships 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. Please email HSC-CPL@salud.unm.edu if you have more than 6 companies to disclose.

Select One of the Following:

𝐁𝐲 𝐞𝐥𝐞𝐜𝐭𝐫𝐨𝐧𝐢𝐜𝐚𝐥𝐥𝐲 𝐬𝐢𝐠𝐧𝐢𝐧𝐠 𝐭𝐡𝐢𝐬 𝐝𝐨𝐜𝐮𝐦𝐞𝐧𝐭, 𝐈 𝐚𝐠𝐫𝐞𝐞 𝐭𝐨 𝐭𝐡𝐞 𝐟𝐨𝐥𝐥𝐨𝐰𝐢𝐧𝐠 𝐞𝐥𝐞𝐦𝐞𝐧𝐭𝐬 𝐚𝐬 𝐞𝐱𝐩𝐞𝐜𝐭𝐞𝐝 𝐨𝐟 𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥𝐬 𝐢𝐧𝐯𝐨𝐥𝐯𝐞𝐝 𝐢𝐧 𝐭𝐡𝐞 𝐩𝐥𝐚𝐧𝐧𝐢𝐧𝐠 𝐚𝐧𝐝 𝐢𝐦𝐩𝐥𝐞𝐦𝐞𝐧𝐭𝐚𝐭𝐢𝐨𝐧 𝐨𝐟 𝐞𝐝𝐮𝐜𝐚𝐭𝐢𝐨𝐧𝐚𝐥 𝐚𝐜𝐭𝐢𝐯𝐢𝐭𝐢𝐞𝐬 𝐜𝐞𝐫𝐭𝐢𝐟𝐢𝐞𝐝 𝐛𝐲 𝐭𝐡𝐞 𝐔𝐧𝐢𝐯𝐞𝐫𝐬𝐢𝐭𝐲 𝐨𝐟 𝐍𝐞𝐰 𝐌𝐞𝐱𝐢𝐜𝐨, 𝐎𝐟𝐟𝐢𝐜𝐞 𝐟𝐨𝐫 𝐂𝐨𝐧𝐭𝐢𝐧𝐮𝐨𝐮𝐬 𝐏𝐫𝐨𝐟𝐞𝐬𝐬𝐢𝐨𝐧𝐚𝐥 𝐋𝐞𝐚𝐫𝐧𝐢𝐧𝐠.

Name

Degree

Date

Coordinator Email

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