CME Activity Planning Committee Disclosure Form

As a provider of Category 1 Continuing Medical Education, The Ohio State University Medical Center must assure balance, independence, objectivity and scientific rigor in all its sponsored educational activities. All individuals who participate in sponsored activities, including activity directors and members of planning committees, are expected to disclose any significant relationships that may pose a conflict with the principles of balance and independence. The following questionnaire will help to evaluate potential conflicts of interest among activity directors and members of the following planning comittee:

Check any commercial, financial, or research relationships or interests within the past 12 months that you, your spouse, or an immediate member of your family, have that might affect your independent involvement in the planning of the proposed CME activity. Consider also, and check, if an organization that you have an affiliation with might benefit from the subject of the proposed CME activity.

Having an interest or affiliation with a corporate organization does not necessarily prevent you from participating in the planning of the proposed CME activity. However, CCME policies describe procedures for resolving conflicts of interest that may require limiting the role and input of any person judged to have a conflict. Your signature below attests to the integrity of the CME planning process and assists in allowing The Ohio State University Medical Center to offer educational activities that are balanced, independent, objective, and that conform to scientific rigor. By choosing 'I accept' to the above information you are attesting it to be true to the best of your information and belief. This statement will be maintained in the CME office as a record of your compliance with the requirements of the CME office.

Date: 11/23/2009