Disclosure Form and Resolution of Conflict of Interest

Course Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Per ARMA requirements, persons who fail to sign and return this form are not eligible to be involved with this activity.

Question Title

* 1. Annual Disclosure for:

Performance Improvement Participant

Committee Member

Activity Director

Presenter

Question Title

* 2. CME Activity or Activities you participate in:

Question Title

* 3. Date of CME Activity:

Dignity Health-EV must ensure balance, independence, objectivity and scientific rigor in its educational activities. List the names of proprietary entities of 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.) with the exemption of non-profit or government organizations and non-health care related companies, with which you or your spouse/partner have, or have had, a relevant financial relationship* within the past 12 months. After you submit the completed disclosure form, it is your responsibility to inform Dignity Health-EV Office of CME if the status of your financial relationship changes prior to your presentation.

Question Title

* 4. With rspect to this CME activity (check one):

No, I do not have a relevant financial relationship.

Yes, I do have a relevant financial relationship.

Question Title

* 5. If yes, please indicate nature of financial relationship:

Consultant, indicate name of company:

Speakers Bureau, indicate name of company:

Grant/Research support, indicate the source of support:

Stock Shareholder, indicate name of company:

Honoraria, please indicate name of company:

Employee, please indicate name of company:

Other, please describe:

Question Title

* 6. Disclosure of Off-Label and/or Investigational Uses

If, at any time, during my education activity I discuss an off-label/investigative (unapproved) use of a commercial product/device, I understand that I must provide disclosure of that intent.

No, I do not intend to discuss an off-label/investigative use of a commercial product/devise.

Yes, I do intend to discuss an off-label/investigative use(s) of the following commercial product(s)/devise(s).

Question Title

* 7. Please provide off-label/investigative use(s) of the following commercial product(s)/device(s):

Manufacturer(s)/Provider(s):

Product(s)/Device(s):

Question Title

* 8. Declaration

I understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).

Electronic Signature

Date

*Glossary of Terms
Commercial Interest: The ARMA defines a commercial interest as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.

Financial Relationship: 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. ARMA considers relationships of the person involved in the CME activity to include financial relationships of a spouse/partner.

Relevant Financial Relationship: ARMA 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. ARMA 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 ARMA defines 'relevant'financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Question Title

* 1. Annual Disclosure for:

Question Title

* 2. CME Activity or Activities you participate in:

Question Title

* 3. Date of CME Activity:

Question Title

* 4. With rspect to this CME activity (check one):

Question Title

* 5. If yes, please indicate nature of financial relationship:

Question Title

* 6. Disclosure of Off-Label and/or Investigational UsesIf, at any time, during my education activity I discuss an off-label/investigative (unapproved) use of a commercial product/device, I understand that I must provide disclosure of that intent.

Question Title

* 7. Please provide off-label/investigative use(s) of the following commercial product(s)/device(s):

Question Title

* 8. DeclarationI understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).

* 6. Disclosure of Off-Label and/or Investigational Uses

If, at any time, during my education activity I discuss an off-label/investigative (unapproved) use of a commercial product/device, I understand that I must provide disclosure of that intent.

* 8. Declaration

I understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).