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ASAM CME Education Disclosure of Relevant Financial Relationships Form

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ASAM CME Education Disclosure of Relevant Financial Relationships Form

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ASAM CE Education Disclosure of Financial Relationships Form

ASAM, as a Jointly Accredited provider, must ensure that this activity and its contents are in full compliance with guidelines prescribed by Joint Accreditation for Interprofessional Continuing Education and the Standards for Integrity and Independence in Accredited Continuing Education (ACE).

All individuals in a position to affect content (including planners, content developers, and presenters) must complete the following financial disclosure form prior to the planning, development, or presentation of an educational activity to ensure adequate review time by the ASAM CE Committee. Please click here to view a letter from the ASAM CE Committee.

 

Glossary of Terms

Ineligible Companies

As defined by ACCME, Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Examples of such organizations include:

The ACCME does not consider providers of clinical service directly to patients to be an ineligible company.

Financial Relationships

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.

Clinical Condition

This is the disease state, clinical condition, or clinical area that a financial relationship relates to or impacts.

 

Instructions



1. Information Needed

Select one of the following statements:

 

 

2. Financial Relationships

Ineligible Company #1

For example: Substance Use Disorder, Infectious Disease, Pain Management

Type of financial relationship. (Select all that apply.)

Ineligible Company #2

For example: Substance Use Disorder, Infectious Disease, Pain Management

Type of financial relationship. (Select all that apply.)

Ineligible Company #3

For example: Substance Use Disorder, Infectious Disease, Pain Management

Type of financial relationship. (Select all that apply.)

Ineligible Company #4

For example: Substance Use Disorder, Infectious Disease, Pain Management

Type of financial relationship. (Select all that apply.)

Ineligible Company #5

For example: Substance Use Disorder, Infectious Disease, Pain Management

Type of financial relationship. (Select all that apply.)

 

 

3. Off-Label Uses

Select one of the following statements:

 

 

4. Agreement

I certify that the information I have provided is complete to the best of my knowledge and I accept responsibility for the accuracy of the information in response to the aforementioned questions. By signing this box with my electronic signature, I attest that all information above is true and correct. I attest that the CE content for which I am responsible will be evidence-based, fair and balanced, unbiased, and free from any ineligible companies’ control. No promotional activities may occur during educational events. This includes distribution of product brochures or product information in conjunction with the educational activity or handouts. No slides or handouts developed by an ineligible company may be used during presentations. I agree to not promote any specific proprietary or ineligible company’s interest in my role as planner or faculty/speaker. I understand that an employee of an ineligible company may NOT serve as a faculty or planner if the educational content that the employee controls relates to the products and/or services of the ineligible company’s employer. If the content DOES NOT relate to the products and/or services of the ineligible company’s employer, the employee may be eligible to serve as speaker or planner, but the educational content must be reviewed (must be sent with the application) before approval of CE credit will be considered. I understand that if I engage in a financial relationship with an ineligible company after the program has been granted accreditation, but before the educational activity has been implemented/delivered, I must alert ASAM and provide a new disclosure form. A second review for approval will become necessary before the activity can be delivered. I understand that if changes are made to my educational presentation/material(s) after the program has been granted accreditation, but before the educational activity has been implemented/delivered, I must alert ASAM and provide information/documentation on the changes. A second review for approval will become necessary before the activity can be delivered. If I have indicated a financial relationship, I understand that this information will be reviewed to determine whether a relevant financial relationship may exist, and I may be asked to provide additional information. I understand that failure to disclose, false disclosure, or inability to mitigate any relevant financial relationships will require the ASAM to identify a replacement or not offer CE credit for this activity.


If you have more than 5 sources of financial relationships with ineligible companies to disclose, email education@asam.org.