A Merican Academy Of Sleep Medicine Disclosure And Resolution

a merican academy of sleep medicine disclosure and resolution of conflicts of interest in cme educational activities as a sponsor acc

A merican Academy of Sleep Medicine
Disclosure and Resolution of Conflicts of Interest in CME Educational
Activities
As a sponsor accredited by the Accreditation Council for Continuing
Medical Education (ACCME), the American Academy of Sleep Medicine must
ensure balance, independence, objectivity, and scientific rigor in all
its sponsored educational activities. All product developers,
planners, speakers, and chairs are expected to disclose any relevant
financial interest or other relationships relevant to the topic of the
presentation held by the individual or members of their family over
the preceding twelve months with (l) the manufacturer(s) of any
commercial product(s) and/or provider(s) of commercial services, (2)
with any commercial supporters, (3) any off-label or investigational
uses of products. The individual is also required to disclose if
he/she has no relationship(s) with any manufacturer(s), product(s) or
service(s). The ACCME also requires product developers, planners,
speakers, and chairs to resolve any conflicts of interest. Therefore,
if you have relevant conflicts, you are asked to declare that you will
recuse yourself from decision-making having to do with the conflict
and/or reference the best available evidence in your
presentation/paper/product and to demonstrate this by providing 2-3
citations that you will refer to.
Educational Product
Your Name:  
Your Role:  
Product Title:  
Question 1:
Each product developer/planner/speaker/chair must disclose a financial
interest or other relationship held by the individual or members of
their family with commercial supporter(s) or with the manufacturer(s)
of commercial product(s)/service(s) over the preceding twelve months
that is relevant to the topic of the presentation. If you do not have
a financial interest or relationship to disclose, please write none on
the line.
Check here if you have nothing to disclose and skip to Question 3.
Consultant:  
Grant/Research Support:  
Speakers’ bureau:  
Investigational Device/Drug:  
Stock/shareholder:*  
Other financial/material support:  
Salary:  
Royalties:  
Intellectual Property Rights:  
*excluding diversified mutual funds
Question 2:
If any financial interest or other relationship has been listed above,
please provide 2-3 citations that are referenced in the presentation
that provide the best evidence in support of the topic:
1.  
2.  
3.  
Question 3:
I agree that I have not received financial support from any
manufacturer of commercial products/services to participate in the
development of this product.
Question 4:
I agree that the best available evidence was referenced in the
development of this product.
   
Signature Date
 
Print Name (please print legibly)
Check this box to represent an electronic signature:
--------------------------------------------------------------------------------------------------------------------------------------------------------
Office Use Only
I have reviewed the above COI form and agree that the planner,
developer, presenter, or chair either has no relevant conflicts of
interest or has established a plan to resolve them
Name:   Date:  
Page 1 of 2 American Academy of Sleep Medicine, Adopted 4/03/2005