Disclosure of Financial Relationships

In accordance with the Standards for Integrity and Independence, GW requires all planners, faculty, and others in a position to control the educational content of an accredited CE activity to disclose the absence or existence of all financial relationships (of any dollar amount) with any ineligible companies within the past 24 months.

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

GW reviews all disclosure statements to determine which financial relationships are relevant to the educational content of the CE activity. An individual is considered to have a relevant financial relationship if the educational content they can control is related to the business lines or products of the ineligible company.

Activity Title: *

Title of Presentation: *

Full Name: *

Name of Employer/Company: *

Title *

Is your employer/company engaged in producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients? *

Yes

No

Are any of the following statements applicable to your role in the planning and/or delivery of this CE activity? *

The content of this CE activity/individual presentation is not related to the business lines or products of my employer/company.

The content of the CE activity/individual presentation is limited to basic science research, such as pre-clinical research and drug discovery, or the methodologies of research, and does not include care recommendations. 

I am participating as a technician in this CE activity and my role is limited to teaching the safe and proper use of a medical device and do not make recommendations on the device’s use on patients.

Content Validity

All speakers, presenters, authors, and writers are expected to identify in their educational content any new and evolving topics for which there is a lower (or absent) evidence base. This includes the discussion of (1) off label/unapproved or investigational uses of FDA approved commercial products or devices and/or (2) products or devices not yet approved in the United States.

Will your presentation include discussion of any new and evolving topics for which there is a lower (or absent) evidence base? *

No

Yes, please describe:

Will your presentation include discussion of any off label/unapproved or investigational uses of FDA approved commercial products or devices? *

No

Yes, please describe:

Will your presentation include discussion of any products or devices not yet approved in the United States? *

No

Yes, please describe:

Disclosure of Financial Relationships

In the past 24 months, have you had any financial relationships with an ineligible company? *

No

Yes

Instructions

For each financial relationship:
- Enter the name of the ineligible company (Examples of Ineligible Companies)
- Select the nature of the financial relationship(s) (Examples of Financial Relationships)
- Indicate if the financial relationship has ended.
- Indicate if the ineligible company has business lines or products related to the content of this CE activity or your individual presentation(s).

Guidance

Individual stocks and stock options should be disclosed.
Diversified mutual funds do not need to be disclosed.
Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.
There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies.
You should disclose all financial relationships regardless of the potential relevance of each relationship to the accredited CE activity.
You may add as many financial relationships as necessary.

1: Name of Ineligible Company:

1: Has the relationship ended within the past 24 months?

If the financial relationship existed during the last 24 months, but has now ended, please select yes.

Yes

No

1: Does this company have business lines or products related to the content of the CE activity or your individual presentation(s)?

Would you like to add additional financial relationships?

Yes

No

2: Name of Ineligible Company:

2: Has the relationship ended within the past 24 months?

If the financial relationship existed during the last 24 months, but has now ended, please select yes.

Yes

No

2: Does this company have business lines or products related to the content of the CE activity or your individual presentation(s)?

Would you like to add additional financial relationships?

Yes

No

3: Name of Ineligible Company:

3: Has the relationship ended within the past 24 month?

If the financial relationship existed during the last 24 months, but has now ended, please select yes.

Yes

No

3: Does this company have business lines or products related to the content of the CE activity or your individual presentation(s)?

Would you like to add additional financial relationships?

Yes

No

4: Name of Ineligible Company:

4: Has the relationship ended within the past 24 month?

If the financial relationship existed during the last 24 months, but has now ended, please select yes.

Yes

No

4: Does this company have business lines or products related to the content of the CE activity or your individual presentation(s)?

Would you like to add additional financial relationships?

Yes

No

5: Name of Ineligible Company:

5: Has the relationship ended within the past 24 month?

If the financial relationship existed during the last 24 months, but has now ended, please select yes.

Yes

No

5: Does this company have business lines or products related to the content of the CE activity or your individual presentation(s)?

Would you like to add additional financial relationships?

Yes

No

Attestation

By submitting this form: *

	Yes	No
I attest that the above information is correct as of this date of submission.	I attest that the above information is correct as of this date of submission. - Yes	I attest that the above information is correct as of this date of submission. - No
I understand that this information will be reviewed to determine whether a conflict of interest may exist, and this information will be provided to participants.	I understand that this information will be reviewed to determine whether a conflict of interest may exist, and this information will be provided to participants. - Yes	I understand that this information will be reviewed to determine whether a conflict of interest may exist, and this information will be provided to participants. - No
I understand that failure or refusal to disclose, false disclosure, or inability to mitigate conflicts of interest will require the GW Office of CEHP to find a substitute planner/presenter.	I understand that failure or refusal to disclose, false disclosure, or inability to mitigate conflicts of interest will require the GW Office of CEHP to find a substitute planner/presenter. - Yes	I understand that failure or refusal to disclose, false disclosure, or inability to mitigate conflicts of interest will require the GW Office of CEHP to find a substitute planner/presenter. - No
I understand that if I enter a new financial relationship between the time, I complete this form and the educational activity, it is my responsibility to notify the GW Office of CEHP prior to the activity..	I understand that if I enter a new financial relationship between the time, I complete this form and the educational activity, it is my responsibility to notify the GW Office of CEHP prior to the activity.. - Yes	I understand that if I enter a new financial relationship between the time, I complete this form and the educational activity, it is my responsibility to notify the GW Office of CEHP prior to the activity.. - No

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