Conflict of Interest

Your Information
* Required Field      
Salutation *    
First Name * Family Name *

Mailing Address * City *
State / Province Country *
    Postal Code*
Home Phone
area code, prefix, number
Preferred Email *
Business Phone
area code, prefix, number
Institution *
Institution Name
Abstract Information
Please list principal author and title of . Full name(s) of the institution(s) is required.
Principal Author First Initial(s)    Last Name
 
Institution Name

city,state,country
Conflict of Interest
     
Faculty or Planning Role:  
Speaker    Co-Author     Other
Please Choose One:      
  I have no financial relationship with a commercial entity producing health-care related products and/or services.
  The commercial entities with which I have relationships do not produce health-care related products or services relevant to the content I am planning, developing or presenting for this activity.
  I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am planning, developing or presenting:
   
Company
Type of Relationship*
Content Area (if applicable)
  1.
  2.
  3.
  4.
  5.
  6.
  7.
    *Type of relationship may include:  full-time or part-time employee, independent contractor, consultant, research or other grand recipient, paid speaker or teacher, membership on advisory committees or review panels, ownership interest (product royalty/licensing fees, owning stocks, shares, etc) or any other financial relationship.
ATTESTATIONS

Please indicate your understanding of and willingness to comply with each statement below.  If you have any questions regarding your ability to comply, please contact the activity coordinator as soon as possible.

 
Agree
Disagree
 
    I have disclosed to SIU School of Medicine all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.
    The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest.  Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.
    I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with the SIU School of Medicine.
    I understand that SIU School of Medicine may need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.
         
  Agree Disagree
N/A
 
  If I am presenting at a live event, I understand that a CME monitor will be attending the event to ensure that my presentation is educational, and not promotional, in nature.
  If I am providing recommendations involving clinical medicine, they 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.  All scientific research referred to, reported or used in CME in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.
  If I am discussing specific healthcare products or services, I will use generic names to the extent possible.  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.
  If I am discussing any product use that is off label, I will disclose that that use or indication in question is not currently approved by the FDA for labeling or advertising.
  If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.

  If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.
         
I have carefully read and considered each item in this form, and have completed it to the best of my ability.