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Activity Title

Activity Date

Identified level of particiption in CME Activity:

Part 1: To be completed by the course director, committee member, speaker, etc.

(1) LIST the names of any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months.

(2) For this purpose we consider the ’relevant’ financial relationships” as financial relationships of your or your spouse/partner in any amount occurring within the past 12 months that create a conflict of interest.

(3) Describe what you or your spouse/partner received (ex: salary, honorarium etc). Foundation for Orthopaedic Research and Education does NOT want to know how much you received.  

(4) Describe your role.  

(5) If no relationship exists, this information must be disclosed as well. 

Have you (or your spouse/partner) had a financial relationship in the last 12 months with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients that will be discussed in the CME activity or in your presentation?

Commercial Interest

Example: Company X

Nature of Relevant Financial Relationship

(include all those that apply)

What was received? Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, etc.

For What Role? Employment, independent contractor, consulting, speaking and teaching, membership on advisory committees or review panels, etc.

Example: Honoraria

Example: Speaker

The following mechanisms have been identified to resolve conflicts of interest.  Please check all that apply: 

Additional information may be requested to resolve any conflict of interest.  Disclosure will be made to the participants prior to the activity.

OFF-LABEL DISCUSSION:

DECLARATION:

  1. All the l the recommendations involving clinical medicine in a CME activity are based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindication in the care of patients.

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

  3. I will uphold academic standards to insure balance, independence, objectivity and scientific rigor.

  4. I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPPAA).  

Disclosure / Contact Form

2023