Forms_Faculty Planning with Disclosures_Template

Faculty Planning with Disclosures

Course Name: *

Please list the course name.

Faculty Name and Professional Title: *

Please list your name and title as they should appear on the website and other promotional materials.

Mobile Number: *

Please enter your contact information so that we can reach you while you're traveling.

Agreement

A. Unbiased and Independent Content

I agree to uphold academic standards to insure independence and scientific rigor in my role in the development and presentation of this CME & CE activity.

I agree to the following statements: *

All recommendations for patient care in accredited continuing education must be based on current science, evidence and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

All scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.

I will omit company logos and brand names from the educational materials that are part of my CME presentation, such as slides, abstracts and handouts.

B. Presentation Guidelines:

My presentation will include slides for *

Disclosure of Financial Relationships

Learning Objectives,

Summary: Key Learning Points with References

Citations and References (evidence-based, peer-reviewed)

C. HIPAA & PHI (Protected Health Information) Laws

I take responsibility for compliance with HIPAA Privacy requirements and applicable state and United States federal laws protecting confidentiality and security of PHI and safeguarding PHI.

I agree to the following statements: *

I have removed all Personal Health Information (PHI) or de-identified images used in my materials including photographs as well as dates of patient care or birth dates (typically found in the margins of clinical images).

When presenting specific patient cases or case histories, I warrant that I have obtained HIPAA compliant authorization for any PHI in my presentation materials.

If my presentation will contain patient identifiers, it is my responsibility to obtain consent from my patients for use of their PHI, including photographic images.

D. Copyright/Fair Use Laws

I agree to the following statements: *

I have obtained permission from copyright holder(s) to reproduce/copy from their work. I acknowledge that Baptist Health South Florida (BHSF) will not be held legally responsible for any misrepresentation on my part regarding copyright infringement.

E. Unlabeled / Unapproved Use

Although accredited continuing education is an appropriate place to discuss, debate, and explore new and evolving topics, these areas need to be clearly identified as such within the program and individual presentations. It is the responsibility of accredited providers to facilitate engagement with these topics without advocating for, or promoting, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning.

I agree to disclose to the audience if my e-Poster includes information about a product not labeled by the FDA for the use under discussion or that is still investigational.

My Presentation: (check one) *

Select one.

DOES NOT include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose.

DOES include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose.

Disclosures

Baptist Health South Florida, an ACCME accredited CME provider, operates within the framework of the Standards for Integrity and Independence in Accredited Continuing Education to insure balance, independence, objectivity and scientific rigor in all of its CME activities. Anyone engaged in content development, planning, review or presentation is obliged to complete this form. 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.

Circumstances create a conflict of interest when an individual has an opportunity to influence or control CME content about products or services of an ineligible company with which he/she has a financial relationship.
The ACCME defines an “ineligible company” as any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
ACCME requires that faculty disclose all financial relationships that you have had in the past 24 months with ineligible companies.

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s).
There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.
NOTICE: Please do not disclose actual financial value of affiliations. Diversified mutual funds are not included in the definition of "commercial interest".

Please check the option that applies to you. *

I, the undersigned, have not had any financial or other relationship(s) with an ineligible company (as defined above) now or within the past 24 months.

Within the past 24 months, I, the undersigned, had a financial relationship, arrangement and/or affiliation with the organizations or companies noted below.

Indicate below the company(ies) with which you or your spouse/partner have (or had) financial relationships and your role, affiliation or financial interest with that company. *

NOTE: Please do not disclose actual financial value of affiliations. Diversified mutual funds are not included in the definition of "commercial interest."

I have received grant/research support from: *

I am a consultant for: *

I am a contractor for: *

I am an advisor for: *

I am an employee/owner of: *

I am an executive of: *

I am the owner of: *

I receive royalties or am a patent beneficiary from: *

I am on the speakers' bureau for: *

I own stock in or am a shareholder of: *

I have other relevant financial relationships to disclose: *

Attestation

I attest that the information provided above is true and correct and that I have read and agree to all the terms of this Invitation as stated and described herein. *

Please sign your name.

Email *

Date *

Month

Day

Year

Need to contact us?

Baptist Health CME
Baptist Health Education Center
Baptist Hospital
8900 North Kendall Drive
Miami, FL 33176

Phone: 786-596-2398
Fax: 786-533-9821
Email: CME12@BaptistHealth.net

You are here

Forms_Faculty Planning with Disclosures_Template

Faculty Planning with Disclosures

Agreement

A. Unbiased and Independent Content

B. Presentation Guidelines:

C. HIPAA & PHI (Protected Health Information) Laws

D. Copyright/Fair Use Laws

E. Unlabeled / Unapproved Use

Disclosures

Attestation

Need to contact us?