VitaeCME Faculty Form for CME Activities

18th April 202026th May 2020

VitaeCME Conflicts of Interest Form for CME Activities

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

Please review our conflict of interest policy, and fill out the form below. 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 Martin Owen (VitaeCME Medical Director) or Kathleen.

Title of Presentation(s): *

Name of Presenter: *

Titles, Degrees, Qualifications

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. *

(A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services. This includes online services, programs and material.)

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

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

Please note that discussion of unapproved or investigational uses of products must be presented in writing to the learners prior to the start of the activity, or at the point that first mention is made of the unapproved/investigational use in the activity.

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 International Institute for Restorative Reproductive Medicine to identify a replacement. *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Date Signed

Name

Advancing Excellence in Restorative Reproductive Medicine

+442032890578
info@iirrm.org
20-22 Wenlock Road London, UK.

EN_GB

ES

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