In accordance with ACCME Standards for Integrity and Independence in Accredited Continuing Medical Education, all planners, teachers, and authors involved in the development of CME content must disclose to the accredited provider their financial relationships that could be perceived as a real or apparent financial relationship in the context of this activity.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). 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 education.

Ineligible Company Definition

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

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. 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.

Administrative

* Activity Title:

* Activity Dates:

* Participant's Name:

* Participant's Email:

* Role:
Presenter Planner of KH event(s) Liaison for KH event(s) Member of KH Advisory Group

In the past 24 months, I HAVE NOT had any financial relationships with any ineligible companies.

In the past 24 months, I HAVE had financial relationships with ineligible companies.

Relationship	List Name(s) of Commercial Entity(ies)
Affiliation/Financial Interest
Grant Research Support
Consultant
Speaker's Bureau
Major Stockholder
Other Financial/Material Support

By submitting this form, you attest to the accuracy of the information you have provided above, and you have agreed to the Planning Committee and Speaker Guidelines.

Contacts: Email Us

Talena Trenum
CME Coordinator
O: (937) 395-6004
F: (937) 522-8930

Martin Jacobs, MD
CME Chair
(937) 395-8611

Agree	Disagree	N/A
			I have disclosed all relevant financial relationships and I will disclose this information to learners.
			I agree to include or provide current references of evidence accepted within the profession of medicine (to the extent possible) as adequate justification for my indications and contraindications in the care of patients.
			I understand that Kettering Health may need to review my presentation and/or content prior to this activity, and I will provide educational content and resources in advance as requested.
			The content and/or presentation of the information with which I am involved will promote quality or improvements in health care. Content for this activity, including any presentation of therapeutic options, will be balanced, evidence-based and commercially unbiased.
			The information presented will be based on generally accepted scientific principals and methods and will not promote the commercial interest (See definition below) of any funding company.
			If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to will conform to the generally accepted standard of experimental design, data collection and analysis.
			If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.
			If I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA.
			I have not and will not accept any honoraria, additional payments or reimbursements directly from a commercial interest (See definition below) for my participation in this activity.

Financial Relationships Form

Ineligible Company Definition

Administrative

Attestations

Commercial Interest Definition

Contacts: Email Us

Financial Relationships Form

Ineligible Company Definition

Administrative

Attestations

Commercial Interest Definition

Contacts: Email Us

Kettering Med Ed CME Contact