Materials Usage Form

As a sponsor accredited by the Accreditation Council for Continuing Medical Education, The Ohio State University Medical Center must insure balance, independence, objectivity, and with scientific rigor in all sponsored or jointly sponsored educational activities. All presenters participating in a sponsored activity are expected to disclose to the audience any significant financial interest or other relationship (1) with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation and (2) with any commercial supports of the activity (Significant financial interest or other relationship can include such things as grants or research support, employee, consultant, major stock holder, member of speakers bureau, etc.) The intent of this disclosure is not to prevent a speaker with a significant financial or other relationship from making a presentation, but rather to provide education with balance, independence, objectivity, and with scientific rigor. Having an interest or affiliation with a corporate organization does not necessarily prevent you from making a presentation. Declining to submit a signed declaration will require The Ohio State University to report nondisclosure to the audience. Any Conflict of Interest must be disclosed with education. The Center for Continuing Medical Education reserves the right to substitute speakers or to decertify program for continuing medical education credit when there appears to be a Conflict of Interest.

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. I understand that information on this form will be made available to anyone associated with this program.

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. Also, The copyright to the presentation material(s) remains with the presenter, unless otherwise covered by the policies of The Ohio State University, including but not limited to the copyright and patent policy. I authorize the Ohio State University Medical Center's Center for Continuing Medical Education to use and reproduce materials, including but not limited to, OSUMedNet21, and in any delivery venue known or not known, in perpetuity, world wide, of the above named presentation. I also grant the Center for Continuing Medical Education a non-exclusive, royalty-free license to distribute these materials for any lawful purpose.

Date: 11/23/2009