Disclosure of Relationships Form

Disclosure of Relationships Form

As an accredited provider of the Accreditation Council for Continuing Medical Education (ACCME), Macon & Joan Brock Virginia Health Science requires disclosure of financial relationships with ineligible companies from any individual in control of the educational content. This includes all planners and speakers. All financial disclosures must be mitigated prior to the activity.

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

The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.
If you have questions, please contact at the CME office at 757-466-6140 or CME@ODU.edu.

Name Name * First Last
Email *
Title of activity (i.e. Grand Rounds, 8th Annual Pediatric Conference, Evening Lecture, etc.) *
Presentation title *
Presentation Date Presentation Date * / MM / DD YYYY
What is your role in regards to this activity? *

What is your role in regards to this activity? Planner Examples: planning committee, staff involved in choosing topics, faculty, or content Teacher, Instructor, Faculty Author, Writer Reviewer Other Other
Identify Financial Relationships

To be completed by planner, faculty member or others who may control educational content
You must disclose ALL financial relationships:

• with ineligible companies, even if you think it is not relevant to the content of the activity.
• regardless of amount (there is no minimum threshold).
• you’ve had for 24 months prior to the activity.
- - Enter the Name of Ineligible Company: An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/rules/standards.
- - Enter the Nature of Financial Relationship: 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.
- - Identify whether the relationship has ended: If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken.
Please Note: Owners and Employees of Ineligible Companies

The owners and employees of ineligible companies must be excluded from controlling content or participating as planners or faculty in accredited education, except in rare, limited and specific circumstances. Owners and employees are individuals who have a legal duty to act in the company's best interests.

Owners are defined as individuals who have an ownership interest in a company, except for stockholders of publicly traded companies, or holders of shares through a pension or mutual fund.

Employees are defined as individuals hired to work for another person or business (the employer) for compensation and who are subject to the employer's direction as to the details of how to perform the job.

If you are a founder/equity owner/employee please include this as a financial relationship. If you receive a salary from that company, this type of relationship is an employee. If you are a founder with a financial interest in the company, this type of relationship is an owner. If you have equity, stock ownership or other investment in the company, you have ownership interest. Please note that there are strict restrictions for employee/owners.
In the past 24 months, I have had financial relationships with ineligible companies. *

In the past 24 months, I have had financial relationships with ineligible companies. Yes No
Ineligible company #1
Name of company #1 *
Financial relationship with company #1 *
Has the relationship with company #1 ended? *

Has the relationship with company #1 ended? Yes No
Add company #2?

Add company #2? Yes No
Ineligible company #2
Name of company #2 *
Financial relationship with company #2 *
Has the relationship with company #2 ended? *

Has the relationship with company #2 ended? Yes No
Add company #3?

Add company #3? Yes No
Ineligible company #3
Name of company #3 *
Financial relationship with company #3 *
Has the relationship with company #3 ended? *

Has the relationship with company #3 ended? Yes No
Add company #4?

Add company #4? Yes No
Ineligible company #4
Name of company #4 *
Financial relationship with company #4 *
Has the relationship with company #4 ended? *

Has the relationship with company #4 ended? Yes No
Add company #5?

Add company #5? Yes No
Ineligible company #5
Name of company #5 *
Financial relationship with company #5 *
Has the relationship with company #5 ended? *

Has the relationship with company #5 ended? Yes No
Add company #6?

Add company #6? Yes No
Ineligible company #6
Name of company #6 *
Financial relationship with company #6 *
Has the relationship with company #6 ended? *

Has the relationship with company #6 ended? Yes No
Add company #7?

Add company #7? Yes No
Ineligible company #7
Name of company #7 *
Financial relationship with company #7 *
Has the relationship with company #7 ended? *

Has the relationship with company #7 ended? Yes No
Add company #8?

Add company #8? Yes No
Ineligible company #8
Name of company #8 *
Financial relationship with company #8 *
Has the relationship with company #8 ended? *

Has the relationship with company #8 ended? Yes No
Add company #9?

Add company #9? Yes No
Ineligible company #9
Name of company #9 *
Financial relationship with company #9 *
Has the relationship with company #9 ended? *

Has the relationship with company #9 ended? Yes No
Add company #10?

Add company #10? Yes No
Ineligible company #10
Name of company #10 *
Financial relationship with company #10 *
Has the relationship with company #10 ended? *

Has the relationship with company #10 ended? Yes No
Add company #11?

Add company #11? Yes No
Ineligible company #11
Name of company #11 *
Financial relationship with company #11 *
Has the relationship with company #11 ended? *

Has the relationship with company #11 ended? Yes No
Add company #12?

Add company #12? Yes No
Ineligible company #12
Name of company #12 *
Financial relationship with company #12 *
Has the relationship with company #12 ended? *

Has the relationship with company #12 ended? Yes No
Add company #13?

Add company #13? Yes No
Ineligible company #13
Name of company #13 *
Financial relationship with company #13 *
Has the relationship with company #13 ended? *

Has the relationship with company #13 ended? Yes No
Add company #14?

Add company #14? Yes No
Ineligible company #14
Name of company #14 *
Financial relationship with company #14 *
Has the relationship with company #14 ended? *

Has the relationship with company #14 ended? Yes No
Add company #15?

Add company #15? Yes No
Ineligible company #15
Name of company #15 *
Financial relationship with company #15 *
Has the relationship with company #15 ended? *

Has the relationship with company #15 ended? Yes No
Add company #16?

Add company #16? Yes No
Ineligible company #16
Name of company #16 *
Financial relationship with company #16 *
Has the relationship with company #16 ended? *

Has the relationship with company #16 ended? Yes No
Add company #17?

Add company #17? Yes No
Ineligible company #17
Name of company #17 *
Financial relationship with company #17 *
Has the relationship with company #17 ended? *

Has the relationship with company #17 ended? Yes No
Add company #18?

Add company #18? Yes No
Ineligible company #18
Name of company #18 *
Financial relationship with company #18 *
Has the relationship with company #18 ended? *

Has the relationship with company #18 ended? Yes No
Add company #19?

Add company #19? Yes No
Ineligible company #19
Name of company #19 *
Financial relationship with company #19 *
Has the relationship with company #19 ended? *

Has the relationship with company #19 ended? Yes No
Add company #20?

Add company #20? Yes No
Ineligible company #20
Name of company #20 *
Financial relationship with company #20 *
Has the relationship with company #20 ended? *

Has the relationship with company #20 ended? Yes No
Add company #21?

Add company #21? Yes No
Ineligible company #21
Name of company #21 *
Financial relationship with company #21 *
Has the relationship with company #21 ended? *

Has the relationship with company #21 ended? Yes No
Add company #22?

Add company #22? Yes No
Ineligible company #22
Name of company #22 *
Financial relationship with company #22 *
Has the relationship with company #22 ended? *

Has the relationship with company #22 ended? Yes No
Add company #23?

Add company #23? Yes No
Ineligible company #23
Name of company #23 *
Financial relationship with company #23 *
Has the relationship with company #23 ended? *

Has the relationship with company #23 ended? Yes No
Add company #24?

Add company #24? Yes No
Ineligible company #24
Name of company #24 *
Financial relationship with #24 *
Has the relationship with company #24 ended? *

Has the relationship with company #24 ended? Yes No
Add company #25?

Add company #25? Yes No
Ineligible company #25
Name of company #25 *
Financial relationship with company #25 *
Has the relationship with company #25 ended? *

Has the relationship with company #25 ended? Yes No
Add company #26?

Add company #26? Yes No
Ineligible company #26
Name of company #26 *
Financial relationship with company #26 *
Has the relationship with company #26 ended? *

Has the relationship with company #26 ended? Yes No
Add company #27?

Add company #27? Yes No
Ineligible company #27
Name of company #27 *
Financial relationship with company #27 *
Has the relationship with company #27 ended? *

Has the relationship with company #27 ended? Yes No
Add company #28?

Add company #28? Yes No
Ineligible company #28
Name of company #28 *
Financial relationship with company #28 *
Has the relationship with company #28 ended? *

Has the relationship with company #28 ended? Yes No
Add company #29?

Add company #29? Yes No
Ineligible company #29
Name of company #29 *
Financial relationship with company #29 *
Has the relationship with company #29 ended? *

Has the relationship with company #29 ended? Yes No
Add company #30?

Add company #30? Yes No
Ineligible company #30
Name of company #30 *
Financial relationship with company #30 *
Has the relationship with company #30 ended? *

Has the relationship with company #30 ended? Yes No
Add another company?

Add another company? Yes No
Please check the boxes below if applicable

Please check the boxes below if applicable My presentation/participation will include products or services of the above ineligible company(ies). My presentation will be fair and balanced and any clinical content presented supports safe, effective patient care.
I attest that the above information is correct as of this date of submission. *

Enter your name
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