- This form is required for all authors and reviewers. Additional information may be required for consultants who are being compensated for effort on an NIH funded grant or contract.
- Content of Activity: ALL
Note: You agree to contact us if this information changes.
First, list the names of commercial interests (defined in the “Glossary of Terms” below) with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
Second, describe what you or your spouse/partner received (ex: salary, fee, research grant, etc). Clinical Tools, Inc. does NOT want to know the amount you received. If relevant financial interest is indicated, we will need to ask you if the amount fits the National Institutes of Health definition of “significant” (which is $5,000 or more or more than 5% ownership) in a calendar year.
Third, describe your role.
Example: Company 'X'
Example: Salary, royalty, intellectual property rights, research grant, consulting fee, speaker fee, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefits.
Example: Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and ‘other activities (please specify).
Please detail other commercial interests, what was received, and for what role you received compensation.
Please upload a digital signature to verify your disclosure.
If no digital signature was uploaded, please type your full name here to verify your disclosure.
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Glossary of Terms
Commercial Interest: The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. For more information, visit www.accme.org.
Financial Relationships: Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefits. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.
Relevant Financial Relationships: ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.