USC SOMG Financial Relationship Disclosure Form

USC SOMG Financial Relationship Disclosure Form

The University of South Carolina School of Medicine Greenville (USC SOMG) is responsible for ensuring that the content of its accredited continuing education activities have been developed independent of commercial bias from financial relationships with ineligible companies. All individuals in a position to control or otherwise influence the content of a USC SOMG accredited continuing education activity are required to disclose any financial relationship(s) with ineligible companies. Prior to the start of the activity, they must also comply with the mechanism(s) the CME Program has chosen to implement for identifying and resolving all relevant financial relationships.

I have read the above statement and understand that failure to comply will result in my disqualification from planning, teaching, or speaking at USC SOMG CME activities.*

Yes

First Name*

Last Name*

Email*

Please use your preferred work email address.

Organization*

If you are not affiliated with Prisma Health, please type your organization into the box below then press 'Enter'.

Select or enter value

In the past 24 months, have you had a financial relationship of any amount with an ineligible company (see definition below)?*

Definition of an Ineligible Company: Any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products or used by or on patients. (For specific examples of ineligible companies visit accme.org/standards.)

No Relationship(s)

Yes Relationship(s)

1.) Commercial Interest Name & Relationship*

For each financial relationship, please list the name of the ineligible company and the nature of the relationship
Examples of financial relationships include: employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties, 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 funds.
Please also list whether this is a current relationship or one you have since divested yourself of (i.e. current or divested)
EXAMPLE(S):
ABC Company, Consultant - Current
Pfizer, Research Grant - Current
Zoll, Speaker's Bureau - Divested

2.) Commercial Interest Name & Relationship

3.) Commercial Interest Name & Relationship

4.) Commercial Interest Name & Relationship

5.) Commercial Interest Name & Relationship

I attest that the above information is correct as of this date of submission. If any changes occur in my financial relationships with ineligible companies, I will promptly submit an updated disclosure form.*

Please check for signature.

Send me a copy of my responses

Privacy Notice|Report Abuse