Joint Providership Information Request

(Provider) is committed to ensuring that all activities are planned and implemented in accordance with the Accreditation Council for Continuing Medical Education (ACCME) Elements, Standards and Policies and to providing clinically relevant educational activities for practitioners to promote improvements or quality in health care that are independent of the control of commercial interests. As part of this commitment, (Provider) does not jointly provide or collaborate on CME activities with commercial interests. A commercial interest is defined by the ACCME as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Standard 1.2 of the ACCME Standards for Commercial Support states that “a commercial interest cannot take the role of non-accredited provider in a joint provider relationship.” Therefore, it is the responsibility of (Provider) to ensure that all non-accredited organizations with which we collaborate are not commercial interests or owned or controlled by a commercial interest. To facilitate the determination of your eligibility to enter into a joint sponsorship relationship with (Provider), we ask that you complete the following questionnaire and return it for our review.

Contact Information

Name of Organization*

Tax ID

Address*

Street Address Address Line 2 City State ZIP Code

Contact Phone*

Fax

Website*

Contact Name*

First Last

Contact Email*

How did you hear about us?*

Mission

Is your organization involved in providing commercial or other company-directed activities or services for pharmaceutical companies, medical device manufacturers, nutraceutical or herbal supplement companies, etc., including but not limited to advertising/promotional services, publication planning, speaker bureau management, speaker training, and advisory board/consultant meeting planning?*

Yes
No

Does your organization, or part of your organization, produce, market, re-sell or distribute health care goods or services consumed by or used on patients?*

Yes
No

Does your organization advocate for an ACCME-defined commercial interest?*

Yes
No

Please provide a brief overview of your organization or attach a copy of your mission statement.*

Corporate Structure

A parent organization is defined as one that owns or fiscally controls another organization. In that context, do you have a parent organization?*

Yes
No

Name

Tax ID

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

If applicable, please provide a brief overview of your parent organization or attach a copy of their mission statement.

If applicable, do you believe that your parent organization is a commercial interest as defined by the ACCME?

Yes
No
N/A

Does your parent company advocate for an ACCME-defined commercial interest?

Yes
No
N/A

Is your organization part of a larger family of companies that is affiliated with any other organization(s) (i.e. do you have any sister companies)?*

Yes
No

If yes, please identify your sister companies (attach additional sheets if necessary).

Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 50 MB.

Name

Tax ID

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

If applicable, is your sister organization a commercial interest as defined by the ACCME?

Yes [complete section IV, Corporate Firewalls]
No [proceed to section V, Attestation]
N/A [proceed to section V, Attestation]

Does your sister company advocate for an ACCME-defined commercial interest?

Yes [complete section IV, Corporate Firewalls]
No [proceed to section V, Attestation]
N/A [proceed to section V, Attestation]

Corporate Firewalls

If any affiliate (sister company) or subsidiary of your organization is involved in providing commercial or other company-directed activities for a commercial interest, you must have a corporate firewall in place to maintain independence in the development of content and implementation of CME activities. Therefore, please verify that your organization has guidelines and firewalls in place to provide for separation of CME and promotional staff (e.g. independent, non-overlapping management, distinct and separate staff responsible for the development of educational content, separate physical locations, different telephone and fax numbers and Internet domains for e-mail addresses, individual computer networks, etc.).

Please describe the elements of your firewall.

Attach an organizational chart that depicts how your organization and management and content-related personnel are distinct and separate from those that are involved in providing commercial or other company-directed activities for a commercial interest.

Accepted file types: jpg, png, gif, pdf, doc, docx, xls, xlsx, Max. file size: 50 MB.

Attestation

I hereby certify that the above information is correct and that (Provider) will be immediately notified if any of the above information changes.

Name

First Last

Date

Phone

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

Joint Providership Information Request

Contact Information

Mission

Corporate Structure

Corporate Firewalls

Attestation

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