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REMINDER: Financial Disclosures are good for 24 months from date of completion.

To be Completed by Planner, Reviewer, Faculty, or Others Who May Control Educational Content

We are looking forward to having the opportunity to include you as a planner/faculty/reviewer in our accredited continuing
education activity.

Why am I receiving this communication?

UT Health San Antonio Office of CME is accredited by the Accreditation Council for Continuing Medical Education
(ACCME). We appreciate your help in partnering with us to follow accreditation guidelines and help us create high-quality
education that is independent of industry influence. In order to participate as a person who will be able to control the
educational content of this accredited CE activity, we ask that you disclose all financial relationships with any ineligible
companies that you have had over the past 24 months. We define INELIGIBLE COMPANIES (formerly Commercial
Support) as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare
products used by or on patients. There is no minimum financial threshold; you must disclose all financial relationships,
regardless of the amount, with ineligible companies. We ask you to disclose regardless of whether you view the financial
relationships as relevant to the education. For more information on the Standards for Integrity and Independence in
Accredited Continuing Education, please visit accme.org/standards.

Why do we collect this information?

Since healthcare professionals serve as the trusted authorities when advising patients, they must protect their learning
environment from industry influence to ensure they remain true to their ethical commitments. Many healthcare
professionals have financial relationships with ineligible companies. By identifying and mitigating relevant financial
relationships, we work together to create a protected space to learn, teach, and engage in scientific discourse free from
influence from organizations that may have an incentive to insert commercial bias into education.

What are the next steps in this process?

After we receive your disclosure information, we will review it to determine whether your financial relationships are
relevant to the education. Please note: the identification of relevant financial relationships does not necessarily mean that
you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation
standards require that relevant financial relationships are mitigated before you assume your role in this activity.

To help us meet these expectations, please use the form we have provided to share all financial relationships you
have had with ineligible companies during the past 24 months. This information is necessary in order for us to be able
to move to the next steps in planning this continuing education activity.

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* 1. Your Name:

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* 2. Credentials: (MD, DO, DPM, RN, PA, etc)

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* 3. You are a (select all that apply):

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* 4. Name of CME Activity:

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* 5. Activity Date:

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* 6. Title of your presentation(s) (Not presentation title) if applicable:

Please check all financial relationships that pertain to ineligible companies.

(Relationships include: Employee and/or Owner; Researcher; Consultant; Advisor; Speaker Bureau;
Independent Contractor; Royalties or Patent Beneficiary; Executive Role; Ownership Interest.)

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* 7. Select one of the following statements:

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* 8. Employee and/or Owner

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* 9. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 10. Researcher. (Research funding from ineligible companies should be disclosed by the principal or named
investigator even if that individual’s institution received the research grant and manages the fund.)

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* 11. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 12. Consultant

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* 13. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 14. Advisor

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* 15. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 16. Speaker Bureau

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* 17. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 18. Independent Contractor (including contracted research)

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* 19. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 20. Royalties or Patent Beneficiary

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* 21. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 22. Executive Role

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* 23. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 24. Ownership Interest. (Individual stocks and stock options should be disclosed. Diversified mutual funds do
not need to be disclosed.)

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* 25. During the last 24 months, has this financial relationship ended (Required field if "yes" checked above.)

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* 26. Do you intend to reference unlabeled/unapproved uses of drugs or products in your presentation?

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* 27. Other

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* 28. Attestation Statement             
                                            
I attest that the above information is correct as of this date of submission.

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* 29. Please provide your email address should we have any questions regarding your disclosure.

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