Education

ASAM Disclosure of Relevant Financial Relationships Form

ASAM Disclosure of Relevant Financial Relationships

ASAM, as the accredited Continuing Medical Education (CME) provider, must ensure that this activity and the presentations are in full compliance with the Accreditation Council for Continuing Medical Education (ACCME) guidelines and Standards for Commercial Support. 

All content developers must complete the following financial disclosure form before any work on their educational activity begins andmust allow adequate review time by the ASAM CME Committee. Please click here to view a letter from the ASAM CME Committee.

Instructions

  • List the names of proprietary entities (see the ACCME definition of a commercial interest listed below) with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
  • Describe what you or your spouse/partner received (ex: salary, honorarium etc).
  • Describe your role.
  • Describe the clinical condition or clinical area that this financial relationship was in (eg, addiction medicine, psychiatry, dermatology).

Glossary of Terms

Commercial Interest
A commercial interest is any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients.
The ACCME does not consider providers of clinical service directly to patients to be commercial interests.
A commercial interest is not eligible for ACCME accreditation. Commercial interests cannot be accredited providers and cannot be joint sponsors. Within the context of this definition and limitation, the ACCME considers the following types or organizations to be eligible for accreditation and free to control the content of CME.

  • 501-C Non-profit organizations (Note: ACCME screens 501c organizations for eligibility. Those that advocate for commercial interests as a 501c organization are not eligible for accreditation in the ACCME system. They cannot serve in the role of joint sponsor, but they can be a commercial supporter.)
  • Government organizations
  • Non-health care related companies
  • Liability insurance providers
  • Health insurance providers
  • Group medical practices
  • For-profit hospitals
  • For-profit rehabilitation centers
  • For-profit nursing homes
  • Blood banks
  • Diagnostic laboratories

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.  ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant Financial Relationships
ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant.  Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of Interest
Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

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

1. Information Needed

Select one of the following statements:

2. Financial Relationships

Commercial Interest #1

For example: Substance Use Disorder, Infectious Disease, Pain Management
Type of financial relationship. (Select all that apply.)






Commercial Interest #2

For example: Substance Use Disorder, Infectious Disease, Pain Management
Type of financial relationship. (Select all that apply.)






Commercial Interest #3

For example: Substance Use Disorder, Infectious Disease, Pain Management
Type of financial relationship. (Select all that apply.)






Commercial Interest #4

For example: Substance Use Disorder, Infectious Disease, Pain Management
Type of financial relationship. (Select all that apply.)






Commercial Interest #5

If you have more then 5 sources of commercial interest to disclose, email CME@asam.org
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

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 commercial interest control. No promotional activities may occur during CE events. This includes distribution of product brochures or product information in conjunction with the educational activity or handouts. No slides or handouts developed by a commercial interest may be used during presentations. I agree to not promote any specific proprietary or commercial business interest in my role as planner or faculty/speaker. I understand that an employee of a commercial interest may NOT serve as a faculty or planner of CE accredited by AANP if the educational content that the employee controls relates to the products and/or services of the commercial interest employer. If the content DOES NOT relate to the products and/or services of the commercial interest 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 serve on a Speakers’ Bureau for the same clinical area as the education activity I plan to provide, and for which accreditation is being requested, my educational activity material(s) must be submitted for a full independent review at the time of the application submission before approval for CE credit will be considered. I understand that if I engage in a financial relationship with a commercial interest after the CE 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 CE program has been granted accreditation, but before the educational activity has been implemented/delivered, I must alert the CE Provider 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 or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure to disclose, false disclosure, or inability to resolve conflicts of interest will require the CE Provider to identify a replacement or not offer CE credit for this activity.