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Family Medicine Education Consortium, Inc. must insure balance, independence, objectivity, and scientific rigor in all its educational activities. All speakers are expected to disclose to the audience any significant financial interest or other relationship with 1) the manufacturer of any commercial product or the provider of commercial services discussed in your educational presentation, or both and 2) any supporters of the conference.
(Significant financial interest or other relationship may include grants or research support, employee, consultant, stockholder, member of speaker’s bureau, owner of a company or product, designer of a product, etc.)
1. Within the past twelve months, I have received support from or have had a relationship with a commercial party related directly or indirectly to the subject of my presentation.
Yes No
If yes, please check all that apply:
2. Will you discuss any off-label uses?
Yes
No
If yes, please identify the product and the unlabeled use.
3. Will you discuss any investigational uses?
Yes
No
If yes, please identify the product and the investigational use.
4. Have you been asked to promote or market any products?
Yes
No
If yes, what products?
5. My participation does not infringe upon any copyright or other intellectual property or proprietary right of any third party. I have obtained appropriate permission to reprint any portion of my presentation.
Yes
No
6. If patient identifying information is used, I have obtained the necessary patient release signatures.
Yes
No
I certify that this information is true and correct. I understand that I am responsible for ensuring that any discussion of investigational and/or off-label uses of a product is disclosed to the audience.
NOTE: Disclosure information will be provided to the audience. Failure to complete this form will be noted as “Refusal to Disclose.”
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