for Continuing Professional Education

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* 1. Full Name and Degree/Credentials

CME/CE Activity Name: 2019 Family Medicine Forum Poster Contest

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* 2. Presentation Title (if applicable)

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* 3. Role(s) (check all that apply)

INSTRUCTIONS FOR DISCLOSURE OF FINANCIAL RELATIONSHIPS WITH COMMERCIAL INTERESTS IN CONTINUING EDUCATION (CME/CE)
  1. RELATIVE TO THIS ACTIVITY, instructors, planners, content reviewers and managers who affect the content of a CME/CE activity are required to disclose financial relationships they have with commercial interests (i.e., any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients).
  2. Disclose financial relationships ONLY with a commercial interest that is relevant to the activity.
  3. You are to disclose financial relationships that fit #2 above in any amount that has been received over the past 12 months ONLY.
  4. Financial relationships with governmental agencies (e.g., the NIH) and organizations that do not fit the above definition do not have to be disclosed.
  5. Honoraria received, or consulting funds, from a CE provider, even though those funds may have been provided to that CME/CE provider through an educational grant from a commercial interest, do not have to be disclosed.
  6. If you are a principal investigator for a drug study, you must report that research relationship below under "Contracted Research" even if those funds came to an institution.
  7. If your spouse or life partner has a relevant financial relationship with an applicable commercial interest (e.g., is employed as the VP-Marketing), or provides marketing advice to an applicable commercial interest as a consultant, you must include that disclosure in the table below.
  8. In accordance with ACCME, ANCC and ACPE requirements, failure to provide disclosure information in a timely manner will result in the disqualification of the potential planner, course director, moderator, faculty, presenter, author or reviewer from this activity.

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* 4. Please confirm that you have read and understood the criteria for disclosing a financial relationship with a commercial interest.

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