Thank you for your involvement in developing education for ACTRIMS. Your role is important to our success. In order to participate in this education, we ask that you disclose all financial relationships with any ineligible company that you have had within the prior 24 months. Guidance about how to complete your disclosure is detailed below. If you have any questions, please contact Heidi Ness at hness@ipmameded.org.

IPMA is accredited by the Accreditation Council for Continuing Medical Education (ACCME). To ensure that we create high-quality education that is independent of industry influence, we adhere to the ACCME Standards for Integrity and Independence in Accredited Continuing Education. These standards require disclosure of all financial relationships with any ineligible company that you have within the prior 24 months.

ACCME defines financial relationships as those relationships in which an individual receives any financial benefit from an ineligible company. The financial nature of such relationships includes but is not limited to employee, researcher, consultant, advisor, speaker, independent contractor, 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. An ineligible company is defined as an entity whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients. Please disclose any relationships regardless of whether you view the financial relationships as relevant to the education.

Owners and employees of ineligible companies are considered to have unresolvable financial relationships and must be excluded from participating as planners or faculty, and must not be allowed to influence or control any aspect of the planning, delivery, or evaluation of accredited continuing education, except in limited circumstances. Subsidiaries of an ineligible parent company are also considered an ineligible company.

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.

This disclosure is not to prevent someone with financial relationships from participating but rather to provide information to evaluate potential bias. An IPMA disclosure reviewer will evaluate the risk for introducing bias into the educational activity and are mitigated as necessary. You must complete this disclosure form before your participation can be confirmed. Your information will be held in confidence in our files.

Directions: Below you will be asked to disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition above). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance to each relationship to the education.

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* 1. Your Full Name

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* 2. Designation (eg. MD, PhD, NP, DO, RN, PA...)

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* 3. Do You Have a Financial Relationship with an Ineligible Company to Report?