1930 Palomar Point Way, Ste. 101 Neuroscience Education Institute Carlsbad, CA 92008 Tel 760-931-8857 Fax 760-931-8713 Full-Disclosure Form NEI requires all planners, teachers/speakers, and authors/content developers involved with CME content to disclose all financial relationships with potential commercial supporters of NEI activities; i.e., manufacturers and/or developers of psychopharmacological substances. Financial relationships reported in this form will be reviewed for any potential conflicts of interest with respect to each activity. Any potential conflicts will be identified and resolved during the planning phase of each activity. Name: ______________________________________________________________________________________ Credentials: _____________________ Title/Affiliation:__________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Please indicate your role in previous/current NEI CME activities (check all that apply): Faculty Author Content Editor Peer Reviewer Course Chair / Planning Committee Editorial / Design Staff Employee Other: _______________________________________ DISCLOSURE Have you (or your spouse/partner) had a financial relationship in the last 12 months with potential commercial supporters Yes No of NEI activities; i.e., manufacturers and/or developers of psychopharmacological substances? If NO, skip to DECLARATION section (last page). If YES, please list your relationships and approaches to resolutions in the COMMERCIAL INTERESTS section below. FINANCIAL RELATIONSHIPS WITH COMMERCIAL INTERESTS -- within the last 12 months Nature of Financial Relationship Divested? Company Name Research Consultant Speakers Board (producers of health care goods or services) Stock Other / Grant / Advisor Bureau Member Abbey Pharmaceuticals Abbott Laboratories Abiant ACADIA Pharmaceuticals Inc. Acologix, Inc. Actelion Ltd Addex Pharmaceuticals SA Addrenex Pharmaceuticals, Inc. Alkermes, Inc. ALZA Corporation Amgen Inc. Amylin Pharmaceuticals, Inc Arena Pharmaceuticals, Inc. Full_Disclosure_Form.doc Page 1 of 6 NEI Full-Disclosure Form, continued continued Company Name Research Consultant Speakers Board Stock Other Divested? (producers of health care goods or services) / Grant / Advisor Bureau Member Asahi Kasei Pharma AstraZeneca Pharmaceuticals LP Avanir Pharmaceuticals Aventis Pharmaceuticals Inc. Avera Pharmaceuticals, Inc. Azur Pharma Inc Barr Laboratories, Inc. Barr Pharmaceuticals, Inc. Becton, Dickenson and Company Biovail Pharmaceuticals, Inc. BMC-JR LLC Boehringer Ingelheim Pharmaceuticals, Inc. BrainCells Inc. Bristol-Myers Squibb Company CeNeRx BioPharma, Inc. Cephalon, Inc. Corcept Therapeutics Inc. Cortex Pharmaceuticals, Inc CSC Pharmaceuticals Cyberonics Cypress Bioscience, Inc. Dainippon Sumitomo Pharma Co., Ltd. Dews Research LLC DOV Pharmaceutical, Inc. Duramed Pharmaceuticals Inc. Eisai Inc. Elan Pharmaceuticals, Inc. Eli Lilly and Company EPIX Pharmaceuticals, Inc. Evotec OAI AG Fabre-Kramer Pharmaceuticals, Inc. Ferring Pharmaceuticals A/S Forest Laboratories, Inc. Forest Pharmaceuticals, Inc. Forest Research Institute Genentech, Inc. GlaxoSmithKline H. Lundbeck A/S Hypnion Inc Hythiam, Inc. Full_Disclosure_Form.doc Page 2 of 6 NEI Full-Disclosure Form, continued continued Company Name Research Consultant Speakers Board Stock Other Divested? (producers of health care goods or services) / Grant / Advisor Bureau Member Janssen, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. Janssen, L.P. Janssen-Ortho Inc. Jazz Pharmaceuticals, Inc. JDS Pharmaceuticals, LLC Johnson & Johnson Johnson & Johnson Pharmaceutical Services, L.L.C. Johnson & Johnson Pharmaceutical Research & Development, L.L.C. King Pharmaceuticals, Inc. KV Pharmaceutical Company Labopharm Inc. LifeScan, Inc. Lundbeck Pharmaceuticals Ltd. Lupin Pharmaceuticals, Inc. Mallinckrodt Pharmaceuticals McNeil Consumer & Specialty Pharmaceuticals McNeil Pharmaceutical MediciNova, Inc. Meiji Pharmaceuticals Co., Ltd. Memory Pharmaceuticals Corp. Merck & Co., Inc. Merck Sharp & Dohme Limited Merck/Schering Plough Neurim Pharmaceuticals (1991) Ltd. Neurochem Inc. Neurocrine Biosciences Inc. Neurogen Corporation NeuroMolecular Pharmaceuticals Neuronetics, Inc. New River Pharmaceuticals Inc. NovaDel Pharma Inc. Novartis Novo Nordisk A/S Omega Pharma NV Orexo AB Organon Orgenics, Ltd. Orphan Medical, Inc. Ortho-McNeil Pharmaceutical Corporation Full_Disclosure_Form.doc Page 3 of 6 NEI Full-Disclosure Form, continued continued Company Name Research Consultant Speakers Board Stock Other Divested? (producers of health care goods or services) / Grant / Advisor Bureau Member Ortho-McNeil Pharmaceutical, Inc. Otsuka America Pharmaceutical, Inc. Pamlab, L.L.C. (Pan American Laboratories, L.L.C.) Parke Davis Pharmaceuticals, Ltd. Pfizer Inc Pharmacia Corporation PharmaNeuroBoost N.V. Pierre Fabre Pierre Fabre Research Institute Prestwick Pharmaceuticals, Inc. The Procter & Gamble Company Promedix Purdue Pharma L.P. Quintiles Transnational Corp. Reevax Pharma Private Limited ResMed Inc. Respironics, Inc. Resteva Roche Pharmaceuticals Sandoz Inc. sanofi-aventis U.S. LLC Sanofi Pasteur Inc. Sanofi-Synthélabo Inc. Schering-Plough Corporation Dr. Willmar Schwabe Pharmaceuticals Schwarz Pharma Inc. Sepracor Inc. Servier Laboratories Shire Pharmaceuticals Inc. SK Bio-Pharmaceuticals SK Corporation Solvay Pharmaceuticals Somaxon Pharmaceuticals, Inc. Supernus Pharmaceuticals, Inc. Synaptic Pharmaceutical Corporation Syrex Takeda Pharmaceuticals North America, Inc. TAP Pharmaceutical Products Inc. Targacept, Inc. Tethys Pharmaceutical, Inc. Tetragenix Pharmaceuticals Full_Disclosure_Form.doc Page 4 of 6 NEI Full-Disclosure Form, continued continued Company Name Research Consultant Speakers Board Stock Other Divested? (producers of health care goods or services) / Grant / Advisor Bureau Member TransOral Pharmaceuticals, Inc. UCB Pharma, Inc Vanda Pharmaceuticals Inc. VivoMetrics, Inc. Wyeth Pharmaceuticals Wyeth Research Wyeth-Ayerst Laboratories Wyeth-Ayerst Pharmaceuticals XenoPort, Inc. Yamanouchi Pharmaceutical Company, Ltd. Full_Disclosure_Form.doc Page 5 of 6 NEI Full-Disclosure Form, continued Will any of the relationships identified above cause the information in the CME content you control to be Yes No commercially biased, or affect your ability to present well-balanced, evidence-based content? If you indicated financial relationships above, you must complete the following section for your disclosure to be considered completed. Mechanisms identified to resolve possible conflicts of interest. Please check all that apply: Presenters/Authors I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature. (See suggested sources of best evidence at www.aafp.org/x3139.xml.) I will refrain from making recommendations regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and/or research findings. I will recommend an alternative presenter for this topic for the planning committee’s consideration. I will submit my presentation in advance to allow for adequate peer review. I will or have divested myself of this financial relationship. Planners To the best of my ability, I will ensure that any speakers or content I suggest are independent of commercial bias. I will recuse myself from planning activity content in which I have a conflict of interest. Additional information may be requested to resolve conflicts of interest. Please be advised that any potential conflicts of interest will be resolved for each activity on a case-by-case basis by NEI’s CME Advisory Board. Financial relationships will be disclosed to participants prior to the activity. DECLARATION 1. I will uphold academic standards to insure balance, independence, objectivity, and scientific rigor in my role in the planning, development, or presentation of all NEI CME activities. 2. I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996. (HIPAA) 3. I will inform learners when I discuss or reference unapproved or unlabeled uses of therapeutic agents or products. Signature: ____________________________________________________________________________ Date: __________________ If you have questions about this policy, please contact NEI’s CME Department at: 888-535-5600. Please fax this completed form to CME’s attention at: 760-931-8713. Full_Disclosure_Form.doc Page 6 of 6 .