Planning Attestation & Commitment Regarding Conflict of Interest (COI)

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Planning Attestation & Commitment Regarding Conflict of Interest (COI) for all Chairs, Co-Chairs, Planners or anyone in control of content

As a provider accredited by the ACCME, Washington University must ensure balance, independence, objectivity and scientific rigor in all of the continuing medical educational activities that it accredits and sponsors. The content or format of CME activities and related materials must be crafted to promote improvements in quality of healthcare and not to promote proprietary business or commercial interest.

All persons in a position to influence the content of an educational activity are expected to disclose to the learners any financial interest or other relationship with a commercial entity, defined as any entity producing, marketing, re-selling, or distributing healthcare goods or services consumed by, or used on, patients. If the activity chairperson/planner and/or activity planning committee members have conflicts that may influence their choice of topics or presenters, a non-conflicted Co-Chair/Planner or an independent reviewer should be involved in the planning. Likewise, if the activity chairperson has a conflict of interest that precludes his or her acting as a reviewer, an alternate reviewer who does not have a conflict should be identified to review the educational materials and plans in order to resolve the conflicts(s) as noted above. Name of Co-Chair/ Independent Reviewer: This person has no COI and has agreed to serve as a Co-Chair or Independent Reviewer of the content of this activity and must also complete this form.

Name of Chairperson/ Co-Chair/Planner/ Independent Reviewer Participation ☐ Activity Chair ☐ Co-Chair ☐ Planner ☐ Independent Reviewer Date of Last Disclosure Financial Relationship(s) Please attach a copy of your current disclosure - either a print out from the CME Any amount disclosure database or a completed form from this packet.

Course Number (if one has been assigned)

Course Title

Review of Planning Process Yes No The agenda does not promote or unfavorably present the product or service of a pharmaceutical or medical device company. The agenda provides a balanced view of therapeutic options that includes pharmacological, invasive, surgical or non-pharmacological approaches. The agenda is designed to promote improvements in the quality of healthcare supported by the best available evidence. The presenters were chosen based upon their level of expertise, not of their relationships 06/2014 with specific companies.

Chair/Planner/Reviewer Signature: ______Date: ______My signature confirms the above guidelines were followed in the planning of the content of this CME Activity.

06/2014