Disclosure of Drugs Form

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					                               UNC CME DISCLOSURE FORM
UNC SOM is accredited as a provider of CME by the Accreditation Council for Continuing Medical Education
(ACCME). UNC SOM requires that all CME activities held under its accreditation be developed independent
of any commercial interest and be scientifically rigorous, balanced, and objective. UNC CME is the designated
office within UNC SOM with the responsibility and aut hority to oversee all CME programs sponsored by UNC

UNC CME has the utmost faith in the integrity of the individuals who present our educational activities.
However, to avoid the appearance of any conflict of int erest, and to comply with the ACCME Standards for
Commercial Support, UNC CME has adopted the following form to identify and resolve any potential co nflicts
of interest. Please see the attached pages for definitions and instructions.

UNC CME also requires presenters to disclose to participants any uses of drugs or devices mentioned in their
presentations that are off-label or investigational (i.e. have not received FDA approval.)

I. DISCLOSURE OF FINANCIAL RELATIONSHIPS- (Please complete all sections.)

Name:                                           Affiliation:
Title of Educational Activity:

Role (please mark all that apply):
  Course Director      Planning Committee              Speaker/Presenter         Panelist     Moderator

Please check one:
    I (and my spouse/partner) have no financial relationships with commercial interests
within the past 12 months

    I (and/or my spouse/partner) have had one or more financial relationships with
commercial interests within the last 12 months. Please indicate the commercial interest, the
clinical/research are involved, and the type of relationship (using the codes listed below). If
the relationship has ended, please indicate the date. Please attach additional pages as
Company        Clinical/Research Relationship Type- Click on Drop               Relationship
Name           Area                 down for list of relationships              Ended- Date
*(includes both contracts in which funding goes directly to you and contracts in which you
are the PI or named investigator, even if the funding goes to your employer.)

If you indicated “other”, please describe:

Disclosure of Unlabeled/Investigational Uses of Products
    I will NOT be planning or presenting information about off-label or investigational uses of
drugs or devices.
   I will be planning or presenting information about off-label or investigational uses of
drugs or devices, and will disclose this to the audience.
II. ATTESTATIONS (Please complete all items.)

   1. I will plan and/or present content at this educational activity that is scientifically
      rigorous, balances, and objective, and that helps to fulfill the purpose and objectives
      of the activity.
                               I agree              I disagree

   2. I will plan and/or present content that is free of commercial bias. I will not promote
      any products or services of commercial interests.
                               I agree                I disagree

   3. I will provide content and materials to UNC CME for review upon request.
                               I agree            I disagree

   4. If my educational content includes references to drugs, devices, or procedures that
      are not approved by the FDA, I will disclose that information to the audience.
                             I agree               I disagree

   5. If I enter any new financial relationship(s) with commercial interests between the time
      I completed this form and the date of the activity, I will notify UNC CME of the new
                               I agree               I disagree

I have carefully considered each item and attest that the information is correct, to the best of
my knowledge.

Name (Print):


This form must be completed and returned in order for you to be involved in the
educational planning and/or presenting of the activity listed above (ACCME SCS 2.2).

Review of Financial Relationships
Date Received:               Date Reviewed:  Reviewer:
Action Taken:

I have reviewed this disclosure information and have resolved all conflicts of interest.

Signature                                                                    Date

                                                                                       3/23/09 DSH

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