Winthrop Faculty Disclosure Form


Your Full Name(*)
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Your Email Address(*)
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Date of CME Activity (You must file Disclosure at least 24 hours in advance of activity date)(*)

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Your Role in this Activity(*)
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Your cell phone if we have questions(*)
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Affiliation/Title/Institution(*)
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Please attach your CV or resume
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Title of Presentation
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If you (or your spouse/partner) had a financial relationship with, and/or received or anticipate any form of remuneration from, in the last 12 months with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, this is a RELEVANT financial relationship you must disclose.
Have you (or your spouse/partner) had a relevant financial relationship, in the last 12 months ?(*)
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(If YES, please list your disclosures)

Please indicate the Type(s) of Relevant Financial Relationship (within past 12 months, include spousal/life partner relationships)


Salary, Royalty, or Honoraria(*)
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Indicate Applicable Manufacturer
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Amount Remuneration
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Receipt of Intellectual Property Rights/Patent Holder(*)
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Indicate Applicable Manufacturer
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Amount of Remuneration
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Consulting Fees (e.g. advisory boards)(*)
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Indicate Applicable Manufacturer
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Amount of Remuneration
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Speakers' Bureaus(*)
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Indicate Applicable Manufacturer
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Amount of Remuneration
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Supported/Contracted Research(*)
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Indicate Applicable Manufacturer
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Amount of Remuneration
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Ownership Interest (stocks, stock options, or other ownership interests [excluding diversified mutual funds])(*)
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Indicate Applicable Manufacturer
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Amount of Remuneration
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Please quote the market value of this ownership as of today's date

If you indicated "Other (Company)" please specify the name of that company
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As a planner, I will ensure that any speakers or content I suggest is independent of commercial bias(*)
RESPONSE REQUIRED:(*)
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As a planner, I will recuse myself from planning activity content in which I have a conflict of interest.(*)
RESPONSE REQUIRED:(*)
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In my role as a planner or speaker at a Winthrop-accredited CME-CE activity, I agree to plan/ present only valid, balanced, independent, objective, and scientifically-based educational content that is free of commercial bias and influence. I agree to comply with all ACCME Standards of Commercial Support and all Federal requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I agree to resolve any relevant conflicts of interest that the CME Office identifies via this disclosure prior to the activity, and to comply with ACCME, ANCC and Winthrop CME-CE compliance policies.(*)
RESPONSE REQUIRED:(*)
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As a speaker, I agree to disclose to learners any discussion of unapproved products or devices, or off-label use of FDA approved products or devices.
RESPONSE REQUIRED:(*)
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I agree to provide updated disclosure immediately for any new financial relationships that arise in the 12 months following the date I have signed this disclosure attestation below.(*)
RESPONSE REQUIRED:(*)
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My signature below indicates that I have read and completed this form myself and to the best of my ability provided current and accurate information. I am aware that financial disclosure information provided in this form will be shared with learners prior to their engagement in this CME/CE activity.(*)
RESPONSE REQUIRED:(*)
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Please type these characters in the field below to prove that you are human(*)
Please type these characters in the field below to prove that you are human
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