CSVS Conflict of Interest Form

The National Standard for Support of Accredited CPD Activities (the National Standard) describes the process and requirements for gathering, managing, and disclosing conflicts of interest to participants. The National Standard is applicable to all accredited CPD activities included within the Canadian national/provincial CME/CPD accreditation systems for physicians.

Definitions:
Conflict of interest: A conflict of interest is a set of conditions in which judgement or decisions concerning a primary interest (example a patients’ welfare, the validity of research and/or quality of medical education) is unduly influenced by a secondary interest (personal or organizational benefit including financial gain, academic or career advancement, or other benefits to family, friends, or colleagues).

Perceived conflict of interest: A perceived conflict of interest is the appearance of a conflict of interest as judged by outside observers regardless of whether an actual conflict of interest exists

Real conflict of interest: A real conflict of interest is when two or more interests are indisputably in conflict.

National Standard Element 3: Conflict of Interest
This element describes the processes and requirements for gathering, managing and disclosing conflicts of interest to participants.
3.1. All members of the SPC, speakers, moderators, facilitators and authors must provide to the CPD provider organization a written description of all relationships with for-profit and not-for-profit organizations over the previous 2 years including (but not necessarily limited to):
a)    Any direct financial payments including receipt of honoraria;
b)    Membership on advisory boards or speakers’ bureaus;
c)    Funded grants or clinical trials;
d)    Patents on a drug, product or device; and
e)    All other investments or relationships that could be seen by a reasonable, well-informed participant as having the potential to influence the content of the educational activity.

3.2. The SPC is responsible to review all disclosed financial relationships of speakers, moderators, facilitators and authors in advance of the CPD activity to determine whether action is required to manage potential or real conflicts of interest. The SPC must also have procedures in place to be followed if a conflict of interest comes to its attention prior to or during the CPD activity.

3.3. All members of the SPC, speakers, moderators, facilitators, and authors, must disclose to participants their relationships as described in 3.1.

3.4. Any individual who fails to disclose their relationships as described in 3.1 and 3.3 cannot participate as a member of the SPC, speaker, moderator, facilitator or author of an accredited CPD activity.

Process
1. Complete the conflict of interest disclosure form and submit to the CPD provider organization or scientific planning committee, as directed.

2. Disclosures must be made to the audience whether you do or do not have a relationship to disclose.

3. Speakers must disclose conflicts verbally and in writing on a slide at the beginning of a presentation. All other individual’s conflicts must be disclosed either in writing on a slide at the beginning of a presentation or be included in the written conference materials.

4. Those responsible for developing or delivering content must ensure that the content and/or materials presented provide (where applicable) a balanced view across all relevant options related to the content area.

5. The description of therapeutic options must utilize generic names (or both generic and trade names) and not reflect exclusivity and branding.

Question Title

* 1. First Name

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* 2. Last Name

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* 3. Email

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* 4. Title of CPD Activity

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* 5. Date of CPD Activity:

Date

Question Title

* 6. Title of presentation/abstract (If you have more than one presentation/abstract, please include all titles)

Title #1

Title #2

Title #3

Title #4

Title #5

Question Title

* 7. What is your role in the CPD activity?

Speaker or Panelist

Member of the planning committee

Moderator, Facilitator or Chair

Author/Co-Author

Abstract Presenter

Other (please specify)

Question Title

* 8. Please indicate:

I do not have a relationship with a FOR-PROFIT and/or a NOT-FOR-PROFIT organization to disclose. (If no, skip questions 6-10)

I have a relationship with a FOR-PROFIT and/or a NOT-FOR-PROFIT organization to disclose. Please indicate the organization(s) with which you have/had a relationship over the previous two years and briefly describe the nature of that relationship.