ࡱ> gih#` $Lbjbj .\ (((8`l|(T8NNN)lW8'''''''$)h&,,'u))'NN`(XNN''V%@%NH @O(VX]% 9&v(0(i%TR-R-%R-%|^qLA''rX($ ((  University of California San Francisco Office of Continuing Medical Education FACULTY DISCLOSURE FORM It is the policy of the University of California San Francisco Office of Continuing Medical Education (OCME) and the University of California CME Consortium to ensure balance, independence, objectivity, and scientific rigor in all CME activities. Anyone engaged in content development, planning or presentation must complete this form. Persons who fail to complete this form will not participate in the CME activity. CME Activity Title:  FORMTEXT       CME Course Number:  FORMTEXT       Title of Presentation:  FORMTEXT       Live Presentation Date:  FORMTEXT       -or-  FORMCHECKBOX  Home Study/Enduring Materials Please indicate your role in this CME activity:  FORMCHECKBOX  Presenter  FORMCHECKBOX  Author  FORMCHECKBOX  Course Director  FORMCHECKBOX  Moderator  FORMCHECKBOX  Planning Committee Member Name:  FORMTEXT       Title:  FORMTEXT       Phone:  FORMTEXT       E-mail:  FORMTEXT       DISCLOSURE  FORMCHECKBOX   FORMCHECKBOX  Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with YES NO a manufacturer of pharmaceutical products or services that will be discussed in this CME activity (planner) or in your presentation (speaker/author)? If NO, skip to DECLARATION section below. If YES, please list your disclosures and approaches to resolutions below Commercial InterestNature of Relevant Financial RelationshipName of CompanyEmployee, Grants/Research Support recipient, Board Member, Advisor or Review Panel member, Consultant, Independent Contractor, Stock Shareholder (excluding mutual funds), Speakers Bureau, Honorarium recipient, Royalty recipient, Holder of Intellectual Property Rights, or Other1. FORMTEXT       FORMTEXT      2. FORMTEXT       FORMTEXT      3. FORMTEXT       FORMTEXT      4. FORMTEXT       FORMTEXT      5. FORMTEXT       FORMTEXT       The following mechanism has been identified to resolve conflicts of interest. 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Presenter/Authors  FORMCHECKBOX  I will submit my presentation in advance for peer review. Chairs/Planners  FORMCHECKBOX  I will submit my program curriculum in advance for peer review.  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 this CME activity. 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  FORMTEXT       Date  FORMTEXT        Please return this form to the program organizer. If you have questions about this form, please contact OCME (415) 476-4251 or to fax this form to OCME our fax number is (415) 476-0318. 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