Cover Sheet for Continuing Activities

COVER SHEET FOR REGULARLY SCHEDULED SERIES Wayne State University School of Medicine Continuing Medical Education Grand Rounds, Case Conferences, Tumor Boards, Journal Clubs All required documentation must be received in the CME Office no later than 60 days after the activity in order to be eligible for CME credit. Activity Title: FORMTEXT Activity Date: Activity Number: Contact Person: Contact Telephone Number:

Learning Objectives for this Session:

Speaker/Presenter/Moderator: Affiliation (Institution): Presentation Title:

(2nd) Speaker/Presenter/Moderator: Affiliation (Institution): Presentation Title:

Check Means of Commercial Relationship Disclosure to the Audience:

Listed in conference materials (brochures, syllabi, flyers) distributed prior to presentations Announced prior to the educational activity. (Attach the wording of the statement and who announced that statement. Sign as witness to the announcement.) The Commercial Relationship Disclosure Forms were PROMINENTLY DISPLAYED at sign-in table (as a separate vertical sign or ON TOP OF Attendance sheets)

Check Means of Commercial Support Disclosure to the Audience (Grants / Exhibits):

Listed in conference materials (brochures, syllabi, flyers) distributed prior to presentations The statement was displayed at sign-in table. (Attach copy) No commercial support

CME Accreditation Statement:

Displayed at sign-in table or on clipboard Displayed in hand-out materials

Required Attachments:

Evaluation Summary or Case List with Recommendations (remove patient identifiers) Commercial Relationship Disclosure forms (Speakers, Moderators, Planning Committee, Case Conference Regular Participants) – once yearly Evidence of Commercial Relationship Disclosure to the Audience Promotional flyer/calendar Journal Article Abstract (Journal Club only) Attendance Rosters or: Clancy Call-In System Commercial Support Letters of Agreement from grants or exhibits (if applicable) – Must be signed and dated prior to the activity Evidence of Commercial Support Disclosure to the Audience (if applicable)