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2015 CFHA Commercial Disclosure Form
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Disclosure for CME Activities

For calendar year 2015


Think you may have already completed a disclosure for calendar year 2015? 

Click here to see 2015 disclosure submissions.

Click here for a list of sessions presenters who STILL NEED TO COMPLETE DISCLOSURE for calendar year 2015.

The Collaborative Family Healthcare Association defines a conflict of interest as any financial or non-financial consideration or relationship relevant to course content that compromises or has the potential to compromise professional judgment. 

All individuals who may affect the content of a continuing education activity must disclose any relevant financial and non-financial relationships during the past 12 months. Relevant financial relationships also include relationships of a spouse or significant other.

The disclosure form must be completed each calendar year by:

  • CFHA Board of Directors
  • Conference Planning Committee members (Policy Forum committee, Social Networking, Steering Committee, etc.)
  • CFHA staff and advisers
  • Conference session Presenters and Co-presenters

A commercial interest is any proprietary entity producing, marketing, re-selling or distributing health care goods or services consumed by or used on patients.

Excluded from the definition of commercial interests are non-profit or government organizations, non-health care related companies, liability insurance companies, health insurance providers, group medical practices, and for-profit hospitals, rehabilitation centers and nursing homes. Refer to Examples below

Relevant financial relationships and conflicts of interest resulting from those relationships must be revealed to the audience and resolved prior to the activity.

Persons refusing to disclose or resolve relevant financial and non-financial relationships will be disqualified from being a part of the planning and implementation of this CME activity. Note that for financial relationships, dollar amounts are not disclosed.

Disclosing such relationships is intended to give Conference attendees a more complete context in which to consider the information you provide. As a general guideline, err on the side of disclosure.

If your presentation is accepted, the information you provide will be disclosed on a Web page and/or printed handout.

In addition, you will be expected to disclose relevant relationships on-site at the time of your presentation, either verbally or visually. 

Example of EXCLUDED relationships include:

    • Employment at an institution of higher learning, teaching hospital or medical practice.

Examples of RELEVANT and disclosable financial relationships may include:

  • Being an employee of, or a paid consultant to, an organization whose product or service you discuss in your presentation
  • Receiving grant funds for a research project you discuss in your presentation
  • Receiving royalties from the sale of a book whose content you discuss in your presentation
  • Patent holder
  • Ownership interest (stocks, stock options or other ownership interests)

Examples of relevant and disclosable non-financial relationships may include:

  • Serving as a formal advisor to a review panel
  • Sitting on the board of an organization whose product or service you discuss in your presentation
  • Receiving an award or honor from an organization whose product or service you discuss in your presentation

 

Skip policy details and go directly to form

 


CME Policy and Procedures for Full Disclosure and Identification and Resolution of Conflicts of Interest

The following policy governs all Collaborative Family Healthcare Association (CFHA) produced CME activities:

1. Disclosure of Financial Relationships: The existence of any financial relationship or interest an individual in a posit ion to influence/control content currently has, or has had, within the last year must be disclosed in writing to learners prior to presentation. Disclosure information must be received and reviewed by CFHA prior to confirmation of the individual’s participation. Any conflicts of interest must be identified and resolved prior to the individual’s confirmation as an activity faculty or other content-influencing/controlling role.

The intent of this policy is not to prevent individuals from participating, but rather is to identify and resolve any conflict of interest. Should resolution be impossible, a replacement for the individual must be chosen.

Because the review, identification, and resolution process must take place prior to the activity, all individuals in a position to influence/control content must return the disclosure information by the due date.

Additional clarification is asked of those who participate in Speakers’ Bureaus to assist CFHA reviewers in understanding the nature of your Speakers’ Bureau relationship (a list of recommended speakers acting independently of any guidance or direction from a commercial entity versus a list of speakers who are acting as agents, or who are contractually bound as agents of the commercial entity) in order to assure that your participation will not be in conflict with previous commitments. The disclosure will be reviewed and, should a conflict be identified, additional information or dialogue may be required. Failure to disclose within the necessary timeframe will result in withdrawal of the invitation to participate.

Acknowledgement of all disclosures—i.e., nothing to disclose or existence of affiliation(s), and/or financial relationship(s) or interest(s)—for every individual who serves in a position to influence/control content of the educational activity must be presented in writing to the learners.

2. Disclosure of Unlabeled/Investigational Uses of Products: Faculty must disclose to CFHA and the learners when an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose, is discussed during an educational activity. Faculty must disclose that the product is not labeled for the use under discussion or that the product is still investigational.

The intent of this policy is not to prohibit or limit the exchange of views in scientific and educational discussions, including discussions of unapproved uses, but to ensure that faculty discloses to learners that such discussion will take place.

Should an unplanned discussion of unlabeled or investigational uses of a product occur (usually in the course of a question and answer session), it is the responsibility of the faculty member to inform the learners that the use under question/discussion is unlabeled or investigational prior to answering the question or responding to the discussion point.

Acknowledgement of planned discussion of unapproved or investigational uses of products must be presented in writing to the learners prior to the start of the activity, or (for enduring materials) at the point that first mention is made of the unapproved/investigational use in the activity.

3. Failure or Refusal to Disclose/False Disclosure: Failure or refusal to disclose, false disclosure, or inability to work with CFHA to resolve an identified conflict of interest will result in withdrawal of the invitation to participate and replacement of the faculty/planner.

4. Identification and Resolution of Conflicts of Interest

A. CFHA will inform all individuals who are invited to serve in roles that may impact the content of an educational activity (faculty, planners, authors, editors, reviewers, staff, etc.) of the CFHA Policy on Full Disclosure. Disclosure forms and due dates will be distributed with the invitation to serve. Confirmation of service is contingent upon return and review of disclosure information and resolution of any conflicts of interest.

B. Each individual faculty/planner/author/editor/reviewer/staff must complete and return his/her disclosure paperwork. CFHA will proceed through a review of the submitted information and, should any of the disclosed information trigger a concern regarding a possible conflict of interest, reviewers may seek input from the candidate and/or other individuals prior to confirming the candidate’s service.

C. Should no conflict of interest be identified, the individual may be confirmed in their role in the activity.

D. Should a conflict of interest be identified, the individual will be contacted and asked for clarification or additional information. Upon receipt and review of this additional information, methods of resolution will be identified and discussed with the individual. Resolution methods may include, but not be limited to, one or more of the following:

    • Assuring valid content through:Evidence-based content using best available, highest strength of evidence
    • Peer review of content prior to the activity; activity faculty must be responsive to revision requirements*
    • Assigning a different topic for the individual
    • Assigning a different faculty for a topic
    • Cancellation of the faculty

E. The resolution process and outcomes will be documented in the CME activity file.

*CFHA considers independent peer review for evidence-based content appropriate action to resolve conflict of interest on the part of speakers and authors.

 


Participant Disclosure Form

For calendar year 2015

If you completed this form for calendar year 2014, you will need to complete in 2015 if you will be involved in leadership and activities related to CE programs and Conference sessions for 2015.

 

* indicates required fields

The Collaborative Family Healthcare Association requires that all individuals who may affect the content of a continuing education activity must disclose any relevant financial and non-financial relationships during the past 12 months. Relevant financial and non-financial relationships also include relationships of an immediate family member.

This disclosure form must be completed each calendar year by:
* Board of Directors
* Conference Planning Committee members
* CFHA staff and advisers
* Conference presenters and co-presenters
* Conference proposal reviewers

There are 6 parts to this disclosure form. You must complete all required fields (*) before submitting this form.
A separate disclosure must be completed for EACH PERSON involved in a CFHA activity for the 2014 calendar year.

(You may attach your CV or include a brief biographical statement at the bottom of the form.)





To comply with the Health Insurance Portability and Accountability Act (HIPAA), we ask that all program planners and instructional personnel insure the privacy of their patients/clients by refraining from using names, photographs, or other patient/client identifiers in course materials without the patient’s/client’s knowledge and written Authorization.

You are required to disclose any relevant financial or non-financial relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners.




Please indicate the names of the organizations with which you have a financial relationship or interest, and the specific clinical areas that correspond to the relationship.











If you checked "Speakers' Bureau" in "Type of Relationships" above, please respond below.

Please check all responses below that apply.







Program Planners/instructional personnel have a relevant non-financial relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners.

Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. May also include personal interest or cultural bias.

Example: Serving on the board of a professional organization without compensation.


FOR PRESENTERS: Please clarify below whether the content of your material(s) and/or presentation(s) for this CME activity will include discussion of unapproved or investigational uses of products or devices.



Please attach your most current resume or CV available, or include a brief biographical statement below.
By accepting below, I acknowledge that I have read the CFHA policy on full disclosure. If I have indicated a relevant relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information.

I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require CFHA to identify a replacement.

I have read the Presenter Details and accept the terms and conditions to present at the CFHA Conference.

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