Faculty Disclosure Form
NEW YORK STATE ACADEMY OF FAMILY PHYSICIANS

CONTINUING MEDICAL EDUCATION DISCLOSURE POLICY

A conflict of interest may be considered to exist if a continuing medical education program faculty (speaker) is affiliated with or has financial interest in any organization(s) that may have a direct interest in the subject matter of the presentation. Situations involving a potential conflict of interest are not inherently bad or wrong, but the prospective audience must be made aware of the affiliation/financial interest via an acknowledgement in conference materials such as brochures, syllabi, exhibits, poster sessions and in post meeting publications. In the case of regularly scheduled events such as grand rounds, the moderators should make disclosure.

For example:

If Dr. Doe is speaking on migraine headaches and currently has an affiliation with XYZ Company and ABC Company:

John Doe, M.D., has disclosed that he participated on a national headache research panel funded by XYZ Pharmaceutical and received honorarium from ABC Pharmaceutical for participating in their speakers bureau on the subject of headache.

Or, if Dr. Doe has financial interest/arrangement*

John Doe, M.D., has disclosed that he holds stock in XYZ Pharmaceutical, and has participated for ABC Pharmaceutical as an expert panel member on clinical topic

*Financial interest/arrangement is defined as being a shareholder, consultant, grant recipient, research participant, employee and/or recipient of other financial or material support.

Or, if Dr. Doe has no affiliation:

John Doe, M.D., has indicated that he has no relationships to disclose relating to the subject matter of his presentation.

Or, if Dr. Doe failed to return his form:

John Doe, M.D., has not returned the disclosure form as of this printing.

The intent of this policy is not to prevent a speaker with an affiliation or financial interest from making a presentation. It is intended that any potential conflict be identified openly so the listeners have the full disclosure of the facts and may form their own judgments about the presentation. The “sunshine” test is the guide for decisions about what to disclose. Any affiliation(s), if made known to the general public, that would cause embarrassment to the individual or institution, or could be perceived as unethical behavior, must be disclosed.

It will be standard procedure of the Academy to acknowledge the type of disclosure – i.e., nothing to disclose; if disclosure, the affiliation and/or financial interest; or disclosure form not returned.

CME Activity Name *
Name *
Your answer
Address
Your answer
Non-Declaration: I, the undersigned, declare that neither I nor any immediate family member currently has a financial arrangement or affiliation with any organization(s) that may have a direct interest in the subject matter of this continuing medical education presentation(s). _______________________________(e-signature)
Your answer
Having an interest in or affiliation with a corporate organization does not necessarily prevent you from presenting, but the relationship must be made known to the audience. **Please add an introductory slide indicating any of the following associations. Declaration:I, the undersigned (or an immediate family member) currently has a financial interest/arrangement or affiliation with the following organization(s) that may have a direct interest in the subject matter of this continuing medical education presentation(s) as follows:
I certify that I have accurately acknowledge that I *
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