Department of Medical Education
Name (print clearly):
NSH medical staff member? Yes No
Email Address:
Activity Date:
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.
Affiliation/Financial Interest
Name of Affiliated
Consultant/Advisory Board
Ownership interest (includes stock, stock
options, patent, or other intellectual property)
Recipient of grant or research support
Other financial or materials support
Submit Form
Attestation for CME Activity
Please indicate your understanding of and willingness to comply with each statement below by checking the
appropriate boxes and placing your signature on the bottom of the page. If you have any questions regarding your
ability to comply, please contact the Northside Hospital Department of Medical Education as soon as possible.
I have disclosed all Financial Relationships that I and/or my spouse have in any amount that have
occurred within the 24 month period preceding the time that I was asked to assume a role
controlling content of the CME activity indicated above. I will disclose this information to the
audience verbally and in the written CME materials, if any. I will have written disclosures approved
by the Northside Hospital Department of Medical Education prior to use.
The content and/or presentation of the information with which I am involved will promote quality
or improvements in healthcare and will not promote a specific proprietary business interest or a
commercial interest. Content for this activity, including any presentation of therapeutic options,
will be well-balanced, evidence-based and unbiased.
I have not and will not accept any honoraria, additional payments or reimbursements beyond that
which has been agreed upon directly with the Northside Hospital Department of Medical
I understand that the Northside Hospital Department of Medical Education will need to review my
presentation and/or content prior to the activity, and I will provide educational content and
resources in advance as requested.
If I am presenting at a live event, I understand that a CME monitor will be attending the event to
ensure that my presentation is educational, and not promotional, in nature.
If I am providing recommendations involving clinical medicine, they will be based on evidence that
is accepted within the profession of medicine as adequate justification for their indications and
contraindications in the care of patients.
All scientific research referred to, reported or used in CME in support of justification of a patient
care recommendation will conform to the generally accepted standards of experimental design,
data collection and analysis.
If I am discussing specific health care products or services, I will use generic names to the extent
possible. If I need to use trade names, I will use trade names from several companies when
available, and not just trade names from any single company.
If I am discussing any product use that is off label, I will disclose that the use or indication in
question is not currently approved by the FDA for labeling or advertising.
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speakers’
bureau) for any commercial interest, the promotional aspects of that presentation will not be
included in any way with this activity.
If I am presenting research funded by a commercial company, the information presented will be
based on generally accepted scientific principles and methods, and will not promote the
commercial interest of the funding company.
I have carefully read and considered each applicable item in this form, and have completed it to the
best of my ability.
Signature Date
By typing my name here I am signing this form
Please return completed form to: Department of Medical Education, or FAX to (404) 256-0113