Disclosure of Commercial Relationships FY: XX
Return completed disclosure to:_Brandy Walker____________e-mail: firstname.lastname@example.org____________by: 04 / 23 / 2012
Person Disclosing:________________________________________ Title :
e-mail:_________________________________________________________Phone : Fax: ________________
Purpose: The disclosure information you provide may be used for activities within the next 12 months or balance of the Fiscal Year. Please complete
this Disclosure of Commercial Relationships with that in mind. Your disclosure information will be considered current for 12 months or balance of the
Fiscal Year. This disclosure addresses requirements of the CE/CME accreditation organizations that accredit the VHA Employee Education System to
help ensure independence in its CE/CME activities. Everyone in a position to control the content of a CE/CME activity must disclose all relevant financial
relationships with commercial interests to the VHA EES. CE/CME providers must resolve current conflicts of interest prior to the educational activity.
Failure to disclose will disqualify you from participation in an EES Activity.
Definition: Financial relationships relevant to the CE/CME activity are those in which an individual (including the individual’s spouse/domestic partner)
(1) A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
(2) A financial relationship exists when 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 benefit. This
includes financial relationships of your spouse or partner.
(3) Control in planning or presenting educational content exists when somebody has influence in the process of needs assessment, faculty selection,
curriculum development, or evaluation of an educational activity.
(4) Conflict of interest can exist when somebody is in control of education content incorporating information about products or services of a
commercial interest with which he/she/spouse/partner has a financial relationship.
Disclosure: Currently or in the past 12 months (check Box 1 or Box 2):
(1) I have no personal financial relationship with a commercial interest.
If this status changes, please notify the VHA EES via email to: EES Disclosures.
(2) I have/had a personal financial relationship with a commercial interest with products or services.
Signature: _________________________________________________________________________________________Date: _________________
Complete both sections below only if you checked Box 2, indicating the presence of a personal financial relationship that is current or ended less than
12 months prior.
Type of Personal Name of Company(s) Relationship Status
Financial Relationship Ended Current*
(For Healthcare Goods / Services)
(Principal Investigator or working directly for company/company’s agent)
(For Drug ,Device or related Communication Company)
Stock Shareholder: _________________________________________________________________
Other: e.g., royalty, patent, employee (describe): _________________________________________
Off Label Uses: Faculty/Authors who plan to discuss off-label uses must disclose this, and how the Learners will be told of the off Label uses.
Do you plan to discuss off-label uses?
NO YES If YES, Please describe: ________________________________________________________________________________
EES Use Only: If current conflicts of interest are present, the person overseeing CE/CME content completes this section.
1. Assessment of presence of a conflict of interest: to be resolved? NO YES (PM completes section below)
2. To assure independence and balance, identified conflicts of interest were resolved by the following process (check one):
Peer review Speaker to use generic names for all drugs in class; will make no specific product recommendations
Individual ended relationship Recommendations based on structured review for best evidence
Committee selected alternate person Other (describe): ______________________________________
CE/CME Name of Activity/Series: _____________________________________________________________________________________________
CE/CME Activity Date/s: __________________________________ Project Manager: ___________________________________________________
EES Privacy Notice:
The privacy of our employees and customers is of the utmost importance to the Department of Veterans Affairs. Any personally identifiable information we request from you will be used for the specifically stated purposes and
will be maintained in a secure system accessible only to authorized people. You do not have to provide the personal information requested, but your participation may be effected if certain personal information is not made
available. To see all your rights regarding the private information you provide to us, please access this webpage: http://vaww.ees.lrn.va.gov/resources/docs/privacy/CV%20Privacy%20Notice%20v1.doc If you do not have access
to the VA intranet, please request this information from the EES contact person above
. Version 3.1 27 Oct 2011