Speaker Conflict of Interest 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 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 speakers of the following CME activity:

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 ability to provide a fair and balanced presentation for 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 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. 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