JP Faculty Agreement & Disclosure Form | CHILD MIND Institute

Name*
First Last Suffix
Email*
Best phone number to reach you*
Activity Date/Title:
Role(s) in Activity (Planning member, Faculty, Author, etc):*
Presentation Title (if applicable or type N/A):*
Name(s) of Faculty Co-Presenting/Panel Members/Co-Authors (if applicable or type N/A):*
Title and affiliation as you would like it to appear in announcements and materials

The purpose of this agreement is to outline the terms and conditions of faculty participating in educational activities certified for continuing education credit. The faculty noted above has reviewed, understands, and accepts the responsibilities outlined in the enclosed confirmation letter and the following rules as required by the approved provider in accordance with guidelines set forth by CME Outfitters in alignment with Joint Accreditation.

DISCLOSURE: All faculty must complete and submit a written disclosure form prior to the presentation and declare that the information provided is complete and truthful to the best of their knowledge. Faculty are required to disclose the existence of any financial relationship they have with the commercial supporter, or other ineligible entities as defined by the ACCME Standards for Integrity and Independence. CME Outfitters is responsible for identifying and mitigating any potential conflicts of interest in compliance with the 2020 updated ACCME Standards for Integrity and Independence.

FREE OF COMMERCIAL BIAS: Faculty are required to prepare non-biased, fair, and balanced presentations that are objective and scientifically rigorous. Furthermore, presentations should be based on the best available evidence and scientific methods generally accepted in the medical community. Personal anecdotes or recommendations based on your personal experience/clinical practice should only be mentioned when evidence-based data is also cited to support the information being discussed.

USE OF GENERIC NAMES: Educational presentations must give a balanced view of therapeutic options. To contribute to this impartiality, faculty are asked to use generic names when referring to therapeutic treatment options. If trade names are used, then those of several companies should also be mentioned rather than only that of a single company.

UNLABELED OR OFF-LABEL (non-FDA-approved) USES OF PRODUCTS: Faculty are required to disclose to the audience when unlabeled use of a commercial product, or an investigational use not yet approved for any purpose, is discussed in their presentation. In addition to disclosure, faculty are also required to reference the best available evidence supporting the discussed usage.

COMMERCIAL SUPPORTER INFLUENCE: Faculty are not permitted to receive any direct funds or gifts from the commercial supporter(s) of this activity as it relates to this specific activity, nor should they be subject to direct input from a commercial supporter regarding the content of their presentation.

COPYRIGHTED MATERIALS: Faculty are responsible for obtaining permissions for all copyrighted materials used in their presentations. Faculty retain copyright in all original materials they contribute to the development of an educational activity.

IMAGE AUTHENTICITY: Faculty are responsible to ensure that all visual images provided to CME Outfitters, LLC for use in this specific activity do not misrepresent or falsify the treatment outcomes described. Any modifications made to better represent the education must be explained and disclosed to the learner.
Faculty Permission
- Yes
- No
Do you agree to allow CME Outfitters, LLC to use your name in program announcements program announcements including but not limited to email, (including using your name as the from field and/or in the subject line), outcomes survey email, social media outlets (Facebook, Twitter, LinkedIn)?

Disclosure of Conflict of Interest
Please disclose 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. You do not need to disclose financial relationships of your 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 accme.org/standards
- No, within the last 24 months, I have not had any type of financial arrangement or affiliation with a commercial interest (as outlined above) that requires disclosure. (click Continue button at bottom of page)
- Yes, within the last 24 months, I have/had a financial arrangement or affiliation with a commercial interest (as outlined above) that requires disclosure. (complete the following section)
If Yes, please provide details in the spaces below:
Grants:
Research Support:
Speakers Bureau:
Consultant:
Stock Shareholder (directly purchased):
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*

JP Faculty Agreement & Disclosure Form | CHILD MIND Institute

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