2025 CME Disclosure of Financial Relationships

Email

This field is for validation purposes and should be left unchanged.

Name*

First Last

Email*

Enter Email Confirm Email

Do you have financial disclosures to report?*

No, neither I nor my spouse/life partner have any financial disclosures to report.

Yes, I or my spouse/life partner have relevant financial relationship(s) and will control educational content of a CME activity.

Relevant financial disclosures include but are not limited to Employee/Salary, Royalty, Patent Holder / Receipt of Intellectual Property Rights, Consulting Fee (e.g. Advisory Boards), Fees for Non-CME services directly from COmmerical Interest or agent * (e.g. Speakers Bureau’s). * An accredited ACCME provider is NOT an agent for a manufacturer. A company acting on behalf of a manufacturer in a promotional activity IS an agent.

Relevant Financial Disclosures

Relevant Financial Disclosures*

Employee/Salary

Royalty

Patent Holder / Receipt of Intellectual Property Rights

Consulting Fee (e.g., Advisory Boards)

Fees for Non-CME Services received directly from Commercial Interest or agent * (e.g., Speakers’ Bureaus)

Contracted Research (PI’s must provide disclosure in this category)

Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds)

Other

Choose all that apply. You will be asked to provide more detail for each area you select. * An accredited ACCME provider is NOT an agent for a manufacturer. A company acting on behalf of a manufacturer in a promotional activity IS an agent.

Employee or Salary received from – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Royalties received from – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Patent Holder / Receiver of Intellectual Property Rights – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Consulting Fee (e.g. Advisory Boards) – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Fees for Non-CME Services received directly from Commercial Interest or Agent (e.g. Speakers' Bureaus) – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Contracted Research (PI's must provide disclosure in this category) – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

Other – INDICATE APPLICABLE MANUFACTURER(S) / COMPANIES Within past 12 months only. Also include those of spouse or life partner*

ATTESTATION TO COMPLY WITH THE ACCME'S VALIDATION VALUE STATEMENTS

Please read the following and indicate your acceptance/acknowledgement by checking the box next to the text.*

I, the person in a position to control or influence content of this educational activity, will ensure the content aligns with the public’s interest and supports the ACCME content validation value statements, which state: (a) All the recommendations involving clinical medicine in a CME activity [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. (b) All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation [conforms] to the generally accepted standards of experimental design, data collection and analysis.

If you reported relationships above, will any of these relationships impact your ability to plan an unbiased program, review in a fair and unbiased manner and/or present an unbiased presentation?*

Yes

No

If you respond yes additional follow-up will be necessary as ACCME requires all those in position to influence content to do so in a fair and unbiased manner.

By Checking Yes below, I certify that the above information is complete and accurate and I will provide updates to ISCD should my disclosures change.*

Yes

Signature*

Please type in your full name as your signature.

Date of Signature*

Month (MM)

Day (DD)

Year (YYYY)