Document Sample
                                (To Be Returned to ASCCP)

We, the undersigned, wish to provide an educational grant to the American Society for Colposcopy and Cervical Pathology
(ASCCP) by means of:

1. Unrestricted educational grant for support of the CME activities in the amount of $______________.

                                    "Friends of ASCCP" Categories (indicate option which applies):
                                     • Sponsor ($6000.00 Educational Grant)

                                     • Equipment Sponsor ($3500.00 Educational Grant)*
                                              * Note: Please see reverse and description page for conditions.

2. Restricted educational grant to reimburse expenses for:
  (Note: This grant category does not include the "Friends of ASCCP" benefits)

                                    a. Support for the Speakers
                                    (A general fund to support travel and honorarium for each faculty member)      $_________

                                    b. Support for catering (please specify coffee break, reception, etc)
                                       __________________________________in the amount of                           $_________

                                    c. Other (e.g., Audience response system, final program/syllabus production)
                                       __________________________________ in the amount of                           $_________


Company Name: ________________________________________________________________________


City/State/Zip Code: ______________________________________________________________________

Telephone:(_____)_______________________________ Fax: (_____)_____________________________


Authorized By: _________________________________________ Title _____________________________

Signature:____________________________________________ Date_____________________________

Method of Payment: _ Check _ Visa           _ MC     _ Am Exp           Card CVS Code ___________________________

Credit Card Number______________________________________ Expiration Date____________________

Name as it appears on credit card___________________________ Signature:__________________________

ASCCP Authorization ____________________________________ Date: ____________________________

                                    Please mail this form along with payment to:
                                                       Ann L. Bass
                                                20 W Washington St, Ste 1
                                               Hagerstown, Maryland 21740
                     Telephone (301) 733-3640 - Fax (301) 733-5775 – www.asccp.org - abass@asccp.org
                                     ASCCP Educational Grant Letter of Agreement


1.       Statement of Purpose: ASCCP strictly adheres to ACCME standards regarding Commercial Support of Continuing Medical
         Education, the AMA’s Guidelines for Gifts from Industry, and the AMA’s E-Addendum II (E-8.061). ASCCP programs and
         courses are for scientific and educational purposes only and will not promote the company’s products, directly, or indirectly.

2.       Control of Content, Presenters and Moderators: ASCCP is responsible for control of content and selection of
         presenters and moderators. ASCCP, in adhering to the ACCME basic design requirements for CME activities, will assure that
         all programs and courses are free of commercial bias for or against any product. The Company agrees not to direct the content
         of the program.

3.       Involvement in Planning and Content: The design, production, delivery and evaluation of educational activities are the
         ultimate responsibility of ASCCP. Commercial supporters shall not control the planning, content or execution of any activity.
         There will be no “scripting”, emphasis, or direction of content by the Company or its agents.

4.       Disclosure of Financial Relationship: ASCCP will ensure meaningful disclosure to the audience, at the time of the
         program, of (a) Company funding, (b) any significant relationship between ASCCP and the Company (e.g. grant recipient,
         speaker’s bureau, consultant), or between individual speakers or moderators and the Company, (c) any faculty member
         reporting no significant financial relationships to disclose; and, (d) any faculty member who has refused to disclose if there are
         any significant financial relationships. ASCCP will publish an annual list of the “Friends of ASCCP” in the October issue of the
         Journal of Lower Genital Tract Disease and include notice of the educational grants.

5.       Ancillary Promotional Activities: No promotional activities will be permitted in the same room or obviate the path of the
         educational activity. No product advertisements will be permitted in the program room or program brochure. Promotional
         activities conducted during non-program hours must be pre-approved by ASCCP at least 20 days prior to the event.

6.       Objectivity and Balance: ASCCP will make every effort to ensure that data regarding the Company’s products (or
         competing products) are objectively selected and presented, with favorable and unfavorable information and balanced
         discussion of prevailing information on the product(s) and/or alternative treatments.

7.       Limitations on Data: ASCCP will ensure, to the extent possible, meaningful disclosure of limitations on data (e.g. ongoing
         research, interim analysis, preliminary data, or unsupported opinion). All recommendations involving clinical medicine in a
         CME activity must be based upon evidence that is accepted with the profession of medicine as adequate justification for their
         indications and contraindications in the care of patients. All scientific research referred to, reported, or used in CME in
         support or justification of a patient care recommendation must conform to general accepted standards of experimental design,
         data collection, and analysis.

8.       Discussion of Unapproved Uses: ASCCP will require that presenters disclose when a product is not approved in the
         United States for the use under discussion.

9.       Opportunities for Debate: ASCCP will ensure meaningful opportunities for questioning or scientific debate.

10.      Independence of ASCCP in the use of Contributed Funds:

         a) the funds should be in the form of an educational grant, made payable to the American Society for Colposcopy and Cervical
         Pathology (ASCCP); and,

         b) no other funds or forms of support from the commercial company will be paid or given to the program director, faculty, or
         others involved with the CME activity (e.g. additional honoraria, extra social events, etc).

The Commercial Supporter agrees to abide by all requirements of the ACCME Standards for Commercial Support of Continuing
Medical Education ({ HYPERLINK "http://www.accme.org" }), the AMA’s Guidelines for Gifts from Industry, and the AMA’s E-
Addendum II (E-8.061).

ASCCP agrees to: 1) abide by the ACCME Standards for Commercial Support of Continuing Medical Education, the AMA’s Guidelines
for Gifts from Industry, and the AMA’s E-Addendum II (E-8.061); 2) acknowledge educational support from the commercial company
in program brochures, syllabi, and other program materials as specified above; and, 3) furnish the commercial supporter with a letter of
agreement or other documentation concerning the expenditures of the funds provided.