CMEO Staff Disclosure Form

What is your role with CMEO? (select all that apply)*

Name*

First Last Suffix

Email*

Disclosure of Financial Relationships*

Please indicate below all financial relationships you have had in the past 24 months with ineligible entities (definition below). For each financial relationship, enter the name of the entity and the nature of the financial relationship. There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible entities. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education. This is only for your personal situation; do not provide any information about a spouse or partner.

NOTE: An ineligible entity is any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. For specific examples, visit https://accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ce/eligibility

No, within the last 24 months, I HAVE NOT had any type of financial arrangement or affiliation with an ineligible company (as outlined above) that requires disclosure.

Yes, within the last 24 months, I HAVE/HAD a financial arrangement or affiliation with an ineligible company (as outlined above) that requires disclosure. I am providing more information below:

If Yes, please provide details in the spaces below:

Advisory Board:

Consultant:

Grants:

Research Support:

Speakers Bureau:

Stock Shareholder (directly purchased):

Stock Shareholder (ownership interest):

Other financial or material support:

Attestation*
I attest that the above information is correct as of date of submission.

Date of submission*
MM slash DD slash YYYY

Signature*

Thank you for completing this important compliance requirement! Should you have questions or concerns, please reach out to Susan Yarbrough, Senior Director at 404.310.5667 or yarbroughs@cmeoutfitters.com.

CMEO Staff Disclosure Form

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