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VitaeCME Faculty Form for CME Activities

18 April 20206 February 2021

VitaeCME Conflicts of Interest Form for CME Activities

Policy and Procedures for Full Disclosure and Identification and Resolution of Conflicts of Interest

Please review Vitae CME's conflict of interest policy, and fill out the form below. When preparing your presentation please ensure the second slide declares any conflicts of interest (or lack thereof) listed below with the audience. Example slides can be provided on request.

If you have any questions or concerns with this form or questions around potential or actual conflicts of interest don't hesitate to reach out to VitaeCME faculty, Kathleen Copeland, or Dr. Martin Owen.

Title of Presentation(s): *

Name of Presenter: *

Degrees, Titles or Professional Affiliations *

Phone Number *

Email *

1. Do you or does any member of your immediate family have a financial relationship or interest with any proprietary entity producing health care goods or services? *

Yes
No

If yes, please check the relationship below: *

Research Grants
Speaking or Presenting
Ownership
Consultant for fee
Employment
Partnership
Stock/ Bond Holdings (excluding mutual funds)
Other: Please describe in the space provided below

Please indicate the names of all organizations in which you have a financial relationship or interest and the specific clinical areas that correspond to the relationship. *

2. Have you receive an honorarium, consulting fee, or any other type of compensation from a proprietary entity producing health goods or services that relate to the topic of your presentation? *

Yes
No

3. Have you participated in any speaker training related to your topic? *

Yes
No

4. Will your presentation include slides or printed materials provided by a proprietary entity? *

Yes
No

5. The content of my material(s)/presentation(s) in this CME activity will include discussion of unapproved or investigational uses of products or devices. *

Yes
No

The intent of disclosing the above is not to prohibit or limit the exchange of views in scientific and educational discussions, including discussions of unapproved uses, but to ensure that faculty discloses to learners that such discussion will take place.

If the answer to any of the questions 2-5 is “yes,” please provide pertinent details below.

6. I give permission to video record my presentation for posting to the VitaeCME website for educational purposes only and share educational materials with learners *

Yes
No
Yes, with limitations.

* A member of the faculty will contact you to work within these limitations if this option is selected.

7. I acknowledge that I will retain all copyright in relation to the text and graphics contained within my presentation, and I consent to the presentation being distributed by IIRRM in the form of electronic files, including slides, audio and video recording to the IIRRM website. This information is made available for educational purposes only and largely will remain limited to current IIRRM members.

Yes
No

I have read the VITAECME Policy and Procedures for Managing Conflicts of Interest, and I have answered these questions to the best of my knowledge. If I have 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 or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require the ViitaeCME to identify a replacement. *