• Online CME Disclosure of All Financial Relationships Form

  • As a Category 1 CME provider, accredited by the ACCME, the Pennsylvania Medical Society requires that all individuals involved in the planning and execution of a Category 1 continuing medical education activity, as either planners, content developers or faculty/presenters, provide disclosure on any financial relationships in any amount that they may have or had with all ineligible companies within the last 24 months. We are specifically asking you to tell us about all financial relationships that you have with ineligible companies, defined as those whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients.

    Examples of any financial relationship may include, but are not limited to: receiving a salary, royalty, intellectual property rights, consulting fee, honorarium, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit associated with roles such as speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. The extent of the relationship should be explained in the description field related to the scope of the relationship in terms of monetary amount received, time frame of relationship, etc.

    As per the ACCME's Standards for Integrity and Independence, any individual who refuses to disclose any financial relationships with ineligible companies "will be disqualified from being a planning committee member, a teacher or an author of CME, and can't have control of, or responsibility for, the development, management, presentation, or evaluation of the CME activity."

     

  • General Information

  • Date of CME Activity:*
     - -
  • My role in the CME activity listed is: *
  • Ineligible Company Financial Relationships

  • Do you have any financial relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients?*
  • Financial Relationships with an Ineligible Company(s)

  • I have the following financial relationship(s) to disclose: (If you have more than three relationships to disclose please email a document with the rest of your relationships to cmeadmin@pamedsoc.org.)

  • Do any of the financial relationships that you have listed relate directly to the content of this CME activity? *
  • Relevant Financial Relationships

  • I attest that I will recuse myself from that portion of the discussion and not influence any decisions related to the content or speakers for this CME activity
  • Verification

  • Should be Empty: