Center for Continuing and Outreach Education
Disclosure Declaration Form - Faculty

As a CME provider accredited by the ACCME, Rutgers, The State University of New Jersey must insure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. As such, Rutgers requires all individuals in a position to control the content of an educational activity to provide a signed disclosure form to the Center for Continuing and Outreach Education (CCOE) prior to the initiation of the activity. In order to ensure its CME activities promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest, CCOE will identify and resolve all conflicts of interest (e.g., peer review) prior to the delivery of the activity to the learner. Based on this disclosure information, CCOE may disqualify any individual from planning and implementation if a conflict of interest that may contribute to commercial bias is determined to exist and cannot be resolved.

Individuals are required to disclose all relevant financial relationships with commercial interests (entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) in any amount as well as the nature of the relationship within the past 12 months. In addition, an individual developing a presentation that provides information, in whole or in part, related to non-FDA approved uses for drug products or devices, must indicate his/her intention to CCOE by way of this form. The individual must also clearly identify the unlabeled indications or the investigational nature of the proposed uses to the learner.

In accordance with the Essential Elements and Standards of Commercial Support set forth by ACCME, the undersigned understands and accepts the policies and standards as set forth in this document.

All disclosure declarations must be communicated to the learner by means of a notation in the program or syllabus, or verbally by the activity director or moderator prior to the beginning of the activity. Individuals who do not provide the requested disclosure information will be disqualified from participating in the development and delivery of a CME activity.

Activity name
21st Annual Fall Scientific Meeting of the SMSNA
Activity location
The Wynn Las Vegas, Las Vegas, NV, USA
Activity dates
November 19-22, 2015

CME Presenter/Author Details

Please fill out all fields and answer all the questions below prior to submitting this form.

1. Presenter (invited presentation or abstract presentation) - ALL QUESTIONS
2. Author (author or co-author of an accepted abstract) - ONLY QUESTION 1
3. Presenter and Author (any combination of 1. and 2.) - ALL QUESTIONS
4. Moderator / Other (if you do not present and are not an author of an abstract) - ONLY QUESTION 1

Question 1

Do you or any member of your immediate family have any relevant financial relationships with commercial interests (entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) in any amount within the past 12 months?
a) If Yes, please list the commercial entities with the type of relationship listed below.
b) If Yes, will your presentation include discussion of specific products/services of the commercial entities you've listed above?

Question 2

During the development and/or presentation of content, I attest to the following:

a) The content and/or the delivery of information in my presentation will promote improvement and quality in healthcare, and will not promote a specific proprietary business interest of a commercial organization.
b) Recommendations involving clinical medicine discussed in my presentation will be based on evidence that is accepted within the profession of medicine that adequately justifies the indications and contraindications in the care of patients.
c) Scientific research referred to, reported or used in my presentation in support or justification of a patient care recommendation conforms to generally accepted standards of experimental design, data collection and analysis.
d) Research findings and therapeutic recommendations discussed in my presentation will be based on scientifically accurate, up-to-date information and presented in a balanced, objective manner.

Question 3

Will your presentation include discussion of unlabeled/investigational uses of a commercial product?
a) If Yes, list the specific product(s) and the off-label or medical indication(s)
This information must be identified and disclosed to the learners during your presentation!


By selecting "I Agree" I certify and acknowledge that (per 2017-11-21):
  • The information I have provided is true and complete to the best of my knowledge and I accept responsibility for the accuracy of the information in response to the aforementioned questions;
  • I will uphold academic standards to ensure balance, independence, objectivity and scientific rigor in my role in the development and implementation of this educational activity;
  • I intend the act of selecting "I Agree" to be my legal signature to this agreement.