Relevant Financial Relationships Mitigation Form

Name Name * First Last
Title of activity *
Topic title *
Date of activity Date of activity * / 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
You have indicated on the “Disclosure of Relationships” form that you have a relevant relationship with an ineligible company. Please confirm that this relationship will not influence the content of your CME program by indicating your understanding of and willingness to comply with each of the following statements.
I have disclosed all financial relationships and this will be disclosed to learners verbally and/or in print. *

I have disclosed all financial relationships and this will be disclosed to learners verbally and/or in print. Yes No
The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of an ineligible company. Content for this activity, including any presentation of therapeutic options will be well-balanced, evidence-based and unbiased. *

The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of an ineligible company. Content for this activity, including any presentation of therapeutic options will be well-balanced, evidence-based and unbiased. Yes No
When discussing specific health care products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company *

When discussing specific health care products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company Yes No
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any ineligible company, the promotional aspects of that presentation will not be included in any way with this activity (i.e. slides from ineligible companies). *

If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any ineligible company, the promotional aspects of that presentation will not be included in any way with this activity (i.e. slides from ineligible companies). Yes No
I will not use commercial logos from any ineligible company in any part of my educational content *

I will not use commercial logos from any ineligible company in any part of my educational content Yes No
When discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA for labeling or advertising. *

When discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA for labeling or advertising. Yes No
I attest that the above information is correct as of date of submission. *

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