Continuing Education Conflict Disclosure Form Please enable JavaScript in your browser to complete this form.Your Name *FirstLastPlease add your credentials after your name. Ex. Jan Spencer, M.D.OTHER Professional Affiliation/RepresentationComment here.Title & Date of Conference *June 8, 2023 - Second Opinion EvaluationsPlease identify the conference or conferences you are participating in.POSITION *Planning Committee MemberSpeaker/PresenterModeratorAdministrative StaffReviewerChoose one category that best describes your level of participation.Your Professional Affiliation/Representation - Check all that applyConsumer Advocate - family member, ally, or consumerDepartment of Developmental DisabilitiesPsychology (Ph.D./Psy.D./Ed.D.)Counseling/Social WorkM.D./D.O.Law, Esq./J.D.NursingOTHEREspecially as members of the Planning Committee it is important that we include all the professions and voices. Do you have a Relevant Financial Relationship to report? *Yes, I will list belowNo, I do NOT have any relevant financial relationships with any 'commercial interests'.If YES, you will be asked to describe the COMMERCIAL INTEREST, WHAT WAS RECEIVED, and for what role. For example: Company Name, HONORARIUM, SpeakerPlease describe any/all Relevant Financial Relationship(s) *List the company or entity name (company name) What was received (honorarium) Role that you played (speaker)EDUCATIONAL ACTIVITY STANDARDS - Please review all.1. All scientific research I refer to, report, and use in the presentation to support patient care recommendations conform to the generally accepted standards of experimental design, data collection, and analysis (addresses content validation). 2. All of the recommendations involving clinical medicine in the presentation are based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients (addresses content validation). Limitations on information, including, but are not limited to data that represents ongoing research; interim analysis; preliminary data; unsupported opinion; or approaches to care that, while supported by some research studies, do not represent the only opinion or approach to care supported by research.3. The content or format of the presentation and all the related materials promote improvements or quality in healthcare and not a specific proprietary business interest or commercial interest (addresses safeguards against commercial bias).4. To use educational materials that do not contain any advertising, trade name, or product-group messages (this addresses educational material).5. To use generic names of medications in all remarks (addresses safeguards against commercial bias).6. If trade names are mentioned, use those from several companies rather than only those of a single supporting company.7. Not to accept any direct remuneration or gifts from commercial supporter(s) of this activity as it relates to this specific activity, nor to accept direct input from commercial supporter(s) regarding presentation content.8. To disclose to the audience all unlabeled or investigational uses of products or services in the remarks.I have read and agree to all of the above: *Clear SignatureSIGNATURE - use your mouse to draw in your signature.Date of signature *Submit Disclosure Form
