2020 SFO CME Disclosure Form

The San Francisco CME Program is required to obtain disclosure information from any person with the ability to influence the content of CME events.

This Disclosure Form should be used by the following:

  • CME Faculty/Presenters/Speakers
  • Planning Committee Members
  • Case Conference Participants
  • CME Committee Members participating in or planning CME programs

As a participant in planning or presenting CME activities you are required to disclose any relevant financial relationship with a commercial interest. The ACCME does not consider providers of clinical service directly to patients to be commercial interests - unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest.

* COMMERCIAL INTEREST: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients. 

* FINANCIAL RELATIONSHIPS: Relationships which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honorarium for promotional speakers' bureau, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.


Please note if in the future there is any change in your disclosure status, a revised Disclosure Form must be completed.

 

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Enter your title for conference publicity (e.g. Chief of Medicine, Institution Name)
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To add multiple emails, separate each email address by a comma.
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Include area code (e.g. 123-456-7890)
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Street address, P.O box, company name, c/o
Apartment, unit, suite, building, floor, etc.
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Enter the dates of your CME activity. If you are unsure of the dates, or are participating in several activities throughout the year, you can type, "Various activities throughout 2020."

Copyright

Original works (published or unpublished), including articles, photographs, cartoons or other images are usually copyright protected and require written permission to use. (Use of facts or ideas does not generally fall under copyright restrictions.)

I understand that I must obtain required permissions for all copyrighted materials I will be using from textbooks, journals, the internet, other print or electronic media.

Content Validation

Evidence citations are required for clinical presentations. All clinical recommendations in a CME activity must be based on accepted medical evidence. Scientific evidence used to support a patient care recommendation must conform to generally accepted standards of medical research. Faculty and presenters may not present patient care recommendations that are not within the definition of CME, that are known to have risks or dangers outweighing benefits, or are known to be ineffective.

Faculty and presenters are required to disclose the sources and levels of evidence to learners when patient care recommendations are made.

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I agree to provide evidence citations for any care recommendations made.
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Relevant Relationships

Under the ACCME Standards for Commercial Support, everyone who is in a position to control the content of an education activity must disclose all relevant financial relationships with any commercial interest. A "commercial interest" includes any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients, with the exception of non-profit or government organizations and non-health care related companies.

A financial relationship is “relevant” if it pertains to the activity's content matter including any related health care products or services to be discussed or presented. ACCME considers financial relationships of the person involved to also include those of a spouse or partner. If a conflict of interest exists, it must be resolved prior to the education activity being delivered. Financial relationships, or the lack of such relationships, must be disclosed to learners prior to the beginning of the educational activity.

Individuals who refuse to disclose financial relationships will be disqualified from participating in the development, management, presentation, evaluation, or approval of the CME activity.

If your financial relationships change prior to your listed CME program(s) or activity(s), you must submit a revised disclosure.

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Describe the nature of the financial relationship(s); List receipt of all salary, grant, research support, royalty, intellectual property rights, consulting fees, honoraria, ownership interests (excluding diversified investment funds), or other financial benefit. Also, please note we will request submission of your slides for review no later than TWO WEEKS prior to your session date.
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If your relevant financial relationships change prior to the CME program(s) or listed activity(s), you must submit a revised disclosure.