Case in Point Forms

Rev. November 2021

Today's Date*

Name of Individual*

Case Suggestion # (eg S2345)*

S#### This number is in your suggestion approval email.

Affiliation*

Diagnosis*

Author title*

If you are an author on the case we need an author disclosure. If non-author signing as submitter's Director/Chair select Non-author to proceed to the Director/Chair Approval section at the bottom.

Select

ASSIGNMENT OF COPYRIGHT

I hereby assign to the American College of Radiology (ACR) my copyright in the case(s) that I have produced and submit to ACR’s Case(s) in Point program. This becomes effective if and when ACR accepts for publication after peer review my case. This transfer will enable ACR to reproduce, print and publish the case electronically or in print. ACR also may provide my case to another radiologist for educational purposes. I will retain copyright if ACR rejects my submission. Whether or not ACR accepts my submission, I will retain all patent and other intellectual property rights to the case. I acknowledge that I must obtain ACR’s prior written permission if I wish to reproduce the case or its contents in any medium for distribution purposes. If ACR grants such permission, I agree to credit ACR as the original source of publication when the case is reproduced. If I wish to use the case or its content in an educational setting without broad distribution, I will not need ACR’s permission. However, I must attribute ACR as the original source of publication. I acknowledge that the case and any accompanying materials will become ACR’s property and that ACR will own the copyright to them. I certify that: a. The content does not infringe any personal or proprietary rights of others. b. I have informed or will inform the Case in Point Editor of any proprietary or commercial interest or conflicts of interest that I may have relating directly or indirectly to this case’s subject. c. I have provided content that complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy standards.

Accredited CE Individuals in Control of Content Annual Financial Relationship Disclosure Form

Purpose

The information you provide addresses requirements of the Accreditation Council for Continuing Medical Education (ACCME) to help ensure integrity and independence in accredited Continuing Education (CE) activities. Everyone in a position to control the content of an accredited CE activity must disclose all financial relationships with ineligible companies, within the past 24 months (whether the relationship has now ended or is currently active) to the American College of Radiology (ACR). The Standards for Integrity and Independence in Accredited CE require that ACR disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited CE. ACR must mitigate relevant financial relationships and disclose these relevant financial relationships to participants prior to the beginning of the activity.

Definition

An ineligible company is any entity whose primary business is producing marketing, selling, re-selling, or distributing healthcare products used by or on patients. Please disclose all financial relationships (any amount) that you have had in the past 24 months with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Disclosure

Regarding my role in accredited CE activities, I have the following financial relationship(s) with ineligible companies:

Name of Company (s)*

Please list the name of company (s) for each financial relationship:

Mitigating Relevant Financial Relationships

Should ACR determine that a disclosed financial relationship is relevant, ACR will begin a series of steps to mitigate the relevant financial relationship and identify what, if any, action is necessary. The review of content will identify potential bias and ensure content is aligned with interests of the learner. Only when the relevant financial relationship has been mitigated may the individual participate in the activity.

Validation Statements

ACR supports the validation of clinical content for all accredited CE activities. Please review the following statements and indicate your intent to comply with each expectation.

I agree:*

All recommendations for patient care in the activity, must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

I agree:*

All scientific research referred to, reported, or used in the activity, in support or justification of patient care recommendation, must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.

I agree*

The content will not advocate for unscientific approaches to diagnosis or therapy, nor promote recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.

Signature & Attestation*

I attest this annual disclosure is correct and complete and will provide any updates/changes to the status of this information during the next year.

Director/Chair Approval Section

Director/Chair Approval*

I understand a resident or fellow listed below is submitting a case or cases to be published in ACR's Case in Point. I have discussed this request with the resident or fellow and approve it. I understand that the resident or fellow may use the case in other educational venues such as lectures or publications, if those uses are compatible with my institution’s interests. First & Last name of submitting author:

Signed attestation of PD/Chair*

Type full name here

CME Activity Name

Send me a copy of my responses

Privacy Notice|Report Abuse