Planning Committee Member Conflict of Interest Disclosure Statement

Below are two date fields that represent a range –start date and end date.  You will be specifying a range of proposed dates - for example between January 1st and January 30th.

  • Please use the first date field to specify a proposed start date. This will be the earliest recommended / proposed date – the beginning of a range of dates.
  •  Then use the 2nd date field to specify a proposed end date (the end of a range of dates)

Note: if you only want to provide one specific date, then please enter this in the Proposed Start Date Range field and ignore the end date.

MM/DD/YYYY

MM/DD/YYYY

*Conflict of Interest Disclosure

All individuals who participate in sponsored activities are expected to disclose any relevant financial relationship that may pose a conflict with the principles of balance and independence.

In the past 12 months have you, your spouse, or any member of your family had a relevant financial or beneficial relationship with any commercial interest?

*A commercial interest is any entity producing, marketing, re-selling, or distributing health care good or services consumed by, or used on, patients. The ACCME considers the following types of organizations to be eligible for accreditation and free to control the content of CME. Relationships with these types of providers need not be disclosed

  • 501-C Non-profit organizations
  • Government organizations
  • Non-health care related companies
  • Liability insurance providers
  • Health insurance providers
  • Group medical practices
  • For-profit hospitals
  • For-profit rehabilitation centers
  • For-profit nursing homes
  • Blood banks
  • Diagnostic laboratories

      
Disclosure Name of Commercial Interest(s):
NoYes
Remuneration (Speaker's Bureau, honoraria, travel expense, etc)
Consultant fees
Grant/Research Support
Major Stock/Shareholder (not mutual funds)
Advisory Board
Ownership or Partnership
*If you check "Yes" in any box above, you must provide the name of the Commercial Interest.  
   
 
Note: Each planning committee member must also submit their CV to the
Office of Continuing Medical Education, Box 70572, Johnson City, TN 37614-0572 through our Fax number (423)439-8040 or by emailing dougherty@etsu.edu
 
 
Click on the Submit button below to complete this application process.
 
You will receive an e-mail confirmation within 24-hours of receipt of submission. 
 
You may print a summary of your responses for your records from the next screen. 
 
Thank you.

 

Revised 12-09-14