Conflict of Interest Disclosure Details Form – Question G
Name: ________________________________________ Job Title: _________________________
Department: ____________________________________________________________________
Part G. Healthcare Industry-Sponsored Activities
1. Name of Healthcare Industry Vendor: _______________________________________________________
2. Where these payments compensation for talks or presentations supported directly by the Healthcare Industry
( ) Yes ( ) No
a. Please check any and all that apply:
Selection of speaker, topic and/or audience was determined by Healthcare Industry sponsor,
supplier or agent.
The content of the lecture was subject to prior review or approval by Healthcare Industry sponsor
representatives or agents.
The lecture content promoted a specific drug, device or service which is manufactured and/or
marketed by the Healthcare Industry event sponsor or its affiliate.
The lecture promoted the use of drugs/devices for indications not approved by the FDA and sold by
the Healthcare Industry vendor sponsoring the lecture.
b. Did anyone besides the event sponsors or affiliates review the content of the presentation to determine
if it is based on a balanced review of the best available scientific evidence?
( ) Yes ( ) No
Reviewed by: ____________________________________________
Phone No.: _______________________________________________
Date: ___________________________________________________
3. Were you receiving payments from the Healthcare Industry vendor for consulting, promoting, lecturing, etc.?
( ) Yes ( ) No
a. Were you receiving payments for these services while conducting research on unapproved indications
of drugs/devices sponsored by the same vendor?
( ) Yes ( ) No
4. Were you paid for any of the following? Please check any and all that apply:
Listening to sales talks
Attending a CME (Continuing Medical Education)
Prescribing medication/changing a prescription
5. Please describe the activities you were compensated for and all associated duties/services: