CONFLICT OF INTEREST (COI) - DISCLOSURE FORM

CONTINUING MEDICAL EDUCATION


The ACCME defines ineligible companies as "those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

For more information on the Standards for Integrity and Independence in Accredited Continuing Education, please visit accme.org/standards.

 
 

Mention "N/A", if you are (Planner/CME Committee member/Organizer etc)

 

This information is necessary in order for us to be able to move forward in this activity.

If an individual refuses to disclose relevant financial relationships to SCOPE, she/he will be disqualified from participating in the accredited activity.

 

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


 

I solemnly affirm the following about this activity:

 

In case of any financial relationship please state:

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.

 
 
 

*Nature of the financial relationship is defined i.e. employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, 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.

 
 

If the financial relationship existed during the last 24 months, but has now ended, please check the box

in this column. This will help the education staff determine if any mitigation steps need to be taken.

 

copy of agreement by the organization

Drop your files here
 

 

Content and Presentation - Validation

Mandatory for speaker / activity directors only

 
 
 
 
 
 

 

General Information

 

Activity Director, Planner, Faculty, Independent Reviewer, Organizer etc

 
 
 
 

Academic Degrees

 
 
 

Attestation

Please read all the statements listed below:


  1. I have disclosed all financial relationships and I will disclose this information to learners.
  2. The content and/or presentation of the information with which I am involved will promote quality or improvements in health care and will not promote a specific proprietary business interest of a commercial interest.
  3. Content for this activity, including any presentation of therapeutic options, will be well balanced, unbiased, and evidence based.
  4. Opinions that are not supported by evidence or are supported by limited or preliminary evidence will be so identified.
  5. Recommendations involving clinical medicine will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.
  6. All scientific research referred to will conform to the generally accepted standard of experimental design, data collection and analysis.
  7. I have not and will not accept any honoraria, additional payments or reimbursements directly for this CE activity from an ineligible company.
  8. I understand that my presentation and/or content may need to be peer-reviewed prior to the activity, and I will provide educational content and resources in advance as requested.
  9. If I am discussing specific healthcare products or services, I will use generic names to the extent possible.
  10. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.
  11. If I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA.
  12. I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
 

Ticking the checkbox below is to be considered the equivalent of my signature. I have read and completed this form to the best of my ability provided current and accurate information.


I am aware that financial disclosure information provided in this form will be shared with learners prior to their engagement in an accredited activity.