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Program Committee Member Disclosure Financial Relationships

This page is for your information only please do NOT return it to the CME office

This is a different form from the one required of MCW faculty each year or for research grants. There are specific requirements of the Accrediting Council for Continuing Medical Education (ACCME).

The purpose of this form is to identify possible conflicts of interest and address them prior to the meeting.
Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or
services of a commercial interest with which he/she has a financial relationship.

Glossary of Terms

Commercial Interest
The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Companies that provide direct patient care such as hospitals and for profit nursing homes, tissue/blood banks, non-profit or government organizations and non-health care related companies such as publishers are not considered commercial interests for CME purposes.

Relationships include financial relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting,
speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. Unpaid advisory board positions and research money or patents given to an institution on an individual's behalf are also considered relevant relationships by the ACCME.

Relevant relationships

The ACCME focuses on relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. Known future relationships are also relevant. There is no minimal amount for relationships to be significant and unpaid advisory board positions are considered relevant. Relationships which are deemed relevant to being a planner or presenter at this meeting will be disclosed to the audience/participants.

If a patent is owned by an individual, it is a relevant item and creates a relevant financial relationship. This must be disclosed to the audience by referring to the owner of the patent by name and a description of what the patent is for.

Program Committee Member Disclosure Financial Relationships
Any details you can provide about how your work with the commercial interest(s) does or does not relate to the content of your presentation will greatly help the CME Office with the process of resolving any possible conflict of interest and approving your talk. For example, there would be no conflict of interest for someone who has received compensation for a presentation on a drug MCW Expectations Please indicate your understanding of, and willingness to comply with, each statement below by checking the appropriate box. If you have any questions regarding your ability to comply, please contact the activity director as soon as possible. No alterations may be made to this form.
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