Department of Medical Education
DISCLOSURE STATEMENT & ATTESTATION
NSH medical staff member? ☐ Yes ☐ No
Role (select all that apply):
Attendee at Case Conference
Member CME Activity Planning Committee
Member CME Program Committee
CME Support Staff
Disclosure for CME Activity
The Northside Hospital Department of Medical Education strives to ensure the balance, independence,
objectivity and scientific rigor of all its continuing medical education (CME) activities. Faculty and
participants of CME activities, and members of CME planning and oversight committees must disclose to
the audience individuals who are in a position to affect the contents of CME activities and must disclose
to participants all their financial relationships with ineligible companies within the prior 24 months.
There is no minimum financial threshold; individuals must disclose all financial relationships, regardless
of the amount, with ineligible companies. Individuals must disclose regardless of their view of the
relevance of the relationship to the education. Examples of financial relationships include employee,
researcher, consultant, advisor, speaker, independent contractor (including contracted research),
royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock
options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding
from ineligible companies should be disclosed by the principal or named investigator even if that
individual’s institution receives the research grant and manages the funds. As an accredited CME
provider, Northside Hospital is required to identify and resolve any potential conflict of interest prior to
you affecting content of any CME activities affiliated with Northside Hospital.
Please choose one of the following:
☐ I do not have any financial relationships to disclose.
☐ I have the following relevant financial relationship(s) as indicated below:
Adherence to conflict of interest policy
In order to resolve conflicts of interest that can arise during the course of planning educational
activities, I agree that I will exclude myself from planning if I have a financial interest or arrangement
with companies related to the topic or topics being planned.
Please remember to sign on the next page.
Name of Affiliated
Ownership interest (includes stock, stock
options, patent, or other intellectual property)
Recipient of grant or research support
Other financial or materials support