ࡱ> OQN\` fbjbj .r F0000 )))8)\P*!D,8+4-J-J-J-./"0D;;;;A&<?fC$MEhGCQE5~.~.E5E5C00J-J-4CS7S7S7E5:0J-08J-;S7E5;S7S70hS7J-,+ z})5:S7o7tC0!DS7{H5{HS7{HS7f0"1S71l21E5E5E5f0f0f0CC=7f0f0f0!DE5E5E5E5))$000000  COMMERCIAL SUPPORT AGREEMENT Regarding Terms, Conditions, and Purposes of an Unrestricted Educational Grant Title of CME Activity: FORMTEXT      Course Number: FORMTEXT      Course Chair(s): FORMTEXT       FORMTEXT       FORMTEXT      Location: FORMTEXT      Date(s): FORMTEXT       Name of company as you would like it to appear in course materials: FORMTEXT      Commercial Supporter (Company Name/Branch): FORMTEXT      Contact Person: FORMTEXT      Address: FORMTEXT      City: FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Telephone:  FORMTEXT      Fax:  FORMTEXT      The company listed above wishes to provide an unrestricted educational grant for support for the above-named CME activity in the amount of:$  FORMTEXT       NOTE TO PROGRAM REPS: Please remember to add your signature and date on the second page. CONDITIONS 1. Statement of Purpose: CME is for scientific and educational purposes only and will not promote any products or services, directly or indirectly. 2. Control of Content & Selection of Presenters & Moderators: UCSF is responsible for the content and selection of presenters and moderators. Any commercial supporter, or its agents, will respond only to UCSF-initiated requests for suggestions of presenters or sources of presenters. UCSF will seek suggestions from other sources and will make the final decision on the presenter(s) selected. 3. Disclosure of Financial Relationships: UCSF will disclose to the audience any significant relationships as specified by ACCMEs Essential Areas and Standards of commercial support. 4. Promotional Activities: No promotional activities will be permitted in the same room or obligate path as the educational activity. 5. Objectivity and Balance: UCSF will ensure that data regarding the commercial supporters products (or competing products) are objectively selected and presented, with favorable and unfavorable information and will ensure balanced discussion of prevailing information on the product(s) and/or alternative treatments. 6. Limitations of Data: UCSF will ensure, to the extent possible, disclosure of limitations of data, (e.g., ongoing research, interim analyses, preliminary data, or unsupported opinion). 7. Discussion of Unapproved Uses: UCSF requires that presenters disclose when a product under discussion is not approved for use in the United States. 8. Opportunities for Debate: UCSF will ensure opportunities for questioning or scientific debate. 9. Independence of Sponsor in the Use of Grant Funds: a. Funds should be in the form of an educational grant made payable to UC Regents. Tax ID# 94-6036493. Please mail payment to: UCSF, Office of Continuing Medical Education, Box 0742, San Francisco, CA 94143-0742. b. All other support associated with this CME activity (e.g., distributing brochures, preparing slides) may only be provided with the full knowledge and approval of the UCSF Office of Continuing Medical Education. c. No other funds from the commercial supporter will be paid to the program director, faculty, or others involved with the CME activity (additional honoraria, extra social events, etc.) The commercial supporter agrees to abide by ACCMEs Standards for Commercial Support. 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AGREED:Company Representative (name):  FORMTEXT      Title:  FORMTEXT      Signature: Date:  FORMTEXT      UCSF - CME Representative (name): Signature:Date:  FORMTEXT       Return this form to:  FORMTEXT        FORMTEXT Address  FORMTEXT City  FORMTEXT State  FORMTEXT Zip Phone:  FORMTEXT HH>IfIhIjIlInIpIrIe[kd$$Ifl4F)*|    4 laf4$1$If5kd$$Ifl4*+4 laf4 XIbIdIjIlItIIIIIIIIIIIIIIIIIIIJ J JJJJbJjJlJnJpJtJJJJJJJJԷȧȔ~ȧk%jh"DCJOJQJU^J*jh"DCJOJQJU^JmHnHu%jh"DCJOJQJU^Jjh"DCJOJQJU^J!jh"DOJQJU^Jh"DCJOJQJ^Jh"DOJQJ^Jjh"DOJQJU^J&jh"DOJQJU^JmHnHu*rItIIII$1$If $$1$Ifa$kkd8$$Ifl\V )* 4 laIIIIII$1$If[kdS$$Ifl4FV )* Z    4 laf4IIIIJJ$1$If $$1$Ifa$kkd$$Ifl\V )* 4 laJJJJJJ$1$Ifnkd$$Ifl4\V )*  4 laf4JJdJfJhJjJ/[kdg$$Ifl4F)*|    4 laf4$1$Ifkkd$$Ifl\V )* 4 lajJlJnJpJrJtJJJJJt  !$1$If $$1$Ifa$kkd $$Ifl\V )* 4 la$1$If JJJJJJJJKKKKK(K*K,K.KBKDKFKTKVKXKZKnKpKrKzK|KKKKзИЩsdЩSdЩ!jM h"DOJQJU^Jh"DOJQJ^JmHnHu!jh"DOJQJU^J&jh"DOJQJU^JmHnHu!jh"DOJQJU^Jjh"DOJQJU^Jh"D5>*OJQJ^Jh"DCJOJQJ^Jh"DOJQJ^Jjh"DCJOJQJU^J*jh"DCJOJQJU^JmHnHuJJJJJJ$1$Ifnkd'$$Ifl4\V )*  4 laf4JJJJJJKK,KXKKKd@dDdFd (#p1$^p1$kkd$$Ifl\V )* 4 laKKKKKKKKKKKKKKKKLd d ddd.d0d2dd@dBdFdHdLdNdRdTd\d^dǶǥ࣏~vrvrvrvrbjh"DCJOJQJU^Jh"Djh"DU!j%h"DOJQJU^J&jh"DOJQJU^JmHnHuU!jy$h"DOJQJU^J!j #h"DOJQJU^Jh"DOJQJ^Jh"DOJQJ^JmHnHujh"DOJQJU^J!j!h"DOJQJU^J$      Fax:  FORMTEXT           EMBED Word.Picture.8UNIVERSITY OF CALIFORNIA, SAN FRANCISCO3333 California Street, Suite 450SCHOOL OF MEDICINESan Francisco, CA 94143-0742OFFICE OF CONTINUING MEDICAL EDUCATIONTelephone: 415.476.4251www.cme.ucsf.eduFax: 415.502.1795 CommericalSupportV70105 CommericalSupportV70105 FdJdLdPdRdVdXdZd\ddd"e$e&eLee]kd6$$Ifl4F\:|)`B6    4 laf4 $ $Ifa$  $If^dddddddd e&eJeLeeeeeff.f0fTf\ffffffh"DOJQJ^Jh"Dh"DCJOJQJaJh"DCJOJQJh"D5CJOJQJh"Djh"DCJOJQJU^Jj'h"DCJOJQJU^J%jIA h"DCJOJQJUV^Jh"DCJOJQJ^Jeeee f f.]kd8$$Ifl4F\:|) B6    4 laf4 $ $Ifa$  $If]kd}7$$Ifl4F\:|) B6    4 laf4 ff0fVfXfZf\ffffffffffgd"DZkd8$$IflF\:|)B6    4 la $ $Ifa$  $Iffffff (#p1$^p,P/ =!"#$% tDText1$$If!vh55555#v#v:V l655/ /  / 4tDText1$$If!vh55555#v#v:V l655/ / 4JD ChairNameXType the full name(s) of the course chair(s). 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Q`*D{ Wk xD q6 x+ d  UTx?  x|P@6 x G x:'''Ht {x) )x  ShfSƄ|l i[ X+gİ'a1`9sb  `7Lx _ G#ί Xģu <  Y O> tn T % X U L -fZ d  U ) [u !5 6U  5 @e U ; . j2 V=6{ :LJ ><,5 i !@] w E} l ."' * m 5 x6 xV S] #5  ?[  m5x !R+C o =www S8 L  Ih C < ,4uG  ]8+,4 3 J < +,4 um != i8 3, X}7x w * +,4 3"N 8?\O ?5 <*+,4H @ **+,4@ 'z. **+,4at 345 **+,43F 6$ |*+,4[IL~ 3j`9*+,4yzp{U P|}*+,4s@touKKvw6x*+,4r*+,4 lMmngoooopq*+,4i?j k*+,4cd efg !h*+,4^_ `a b*+,4Z5[\ ]*+,4RST U$VWXY*+,4 J KLMNOP Q*+,4 @ABCDEFG HI< +"4 5=> ?8+,4 9: ;* 3"4 561 7* +,- ./0 12 !"#$%& '()  ''- 2  8'-D2 "&l OFFICE OF CONTINUING MEDICAL EDUCATION:..62:.6:6.666:?2665.26665.:6- 2 "B l  8l '-.2 l rTelephone: 415.476.42513-*****************- 2 Hl r 8rl ' 2 , 8'-2 o www.cme555&?*2  o .ucsf.edu*&&***- 2 B o  8o '-&2 wi uFax: 415.502.1795.*$**********- 2 wHi u 8ui ' 2 , :'-.2 ,CommericalSupportV7010536*??*&*2****2***** 2  ('@ Arial- 2 j, 352 COMMERCIAL SUPPORT AGREEMENTBHMM=BB?8=B==HB7?HB==M=B7 2 K  3-2 4NRegarding Terms, Conditions, and Purposes of an Unrestricted Educational Grant<......4.G*<.....*...7...*.*...<..**..7..*....A.. 2 4 - 2   -@ Arial-2   m 2 x  1-,2 W,Title of CME Activity:4..<E77*)' 2 W& .' 2 W+ 2 W+ :. 2 W+ 2 W+ . 2 W+ 2 W+ :. 2 WL+ 2 WL+ . 2 Wz+ 2 Wz+ :. 2 W+ :. 2 WX%  :. %' 2 W  W :. 2 WQ :.Q'- @ ! -- @ ! -- @ ! -- @ ! -- @ ! -- @ ! 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X-- @ ! -- @ ! -- @ !\ -- @ !\ - 2 ,Course Number:<..*.<.G.. 2  :.' 2 + 2 + . 2 + 2 + :. 2 + 2 + . 2 L+ 2 L+ :. 2 z+ 2 z+ . 2 + . 2 X%  . %' 2   W . 2 Q .Q'- @ !\i-- @ !\i-#2 ,Course Chair(s):<..*.<..* 2  .' 2 + 2 + :. 2 + 2 + . 2 + 2 + :. 2 L+ 2 L+ . 2 z+ 2 z+ :. 2 + :. 2 X%  2 X%  . 2 %  2 %  :. 2 %  2 %  . 2 %  2 %  :. 2  %  2  %  . 2 > %  . %' 2   W 2   W :. 2   W 2   W . 2 J  W 2 J  W :. 2 x  W 2 x  W . 2   W 2   W :. 2   W :. 2 Q :.Q'- @ !\-- @ !\-@ Arial- -2 k,Location..*...- 2 ke:: 2 k| :-'- 2 k+ 2 k+ . 2 k+ 2 k+ :. 2 k+ 2 k+ . 2 kL+ 2 kL+ :. 2 kz+ 2 kz+ . 2 k+ .2 kX% Date(s):<..* 2 k %  . %' 2 k  W 2 k  W :. 2 k  W 2 k  W . 2 kJ  W 2 kJ  W :. 2 kx  W 2 kx  W . 2 k  W 2 k  W :. 2 k  W :. 2 kQ :.Q'- @ !]!-- @ !~-- @ !~-- @ !~-- @ !~-- @ !~-- @ !~%-- @ !~)-- @ !~ -- @ !~ -- @ !~Q-- @ !~U-- @ !]!-- @ !~-- @ !~- 2 , :-' 2 (, :-'-p2 ,CName of company as you would like it to appear in course materials:B3R3838R838133188J88833838833$8388$33R33$33- 2   :3'- @ !:-- @ !:-- @ !:-- @ !:-- @ !:-- @ !k>-- @ !k>-- 2 , 2 , . 2 Z 2 Z :. 2  2  . 2  2  :. 2  2  .- @ !,- @ Arial- 2  .- @ !\-- @ !\--L2 O,+ Commercial Supporter (Company Name/Branch):<.GG.*.7.....<.G...'<.G.7..*. 2 OI  . 2 O#   2 O#   :. 2 OQ   2 OQ   . 2 O   2 O   :. 2 O   2 O   . 2 O   2 O   :. 2 O   :.- @ !\-- @ !\-2 , Contact Perso<...*7.*.2 :n:. 2  :. 2 r 2 r . 2 *r 2 *r :. 2 Xr 2 Xr . 2 r 2 r :. 2 r 2 r . 2 r . 2 l .l'- @ !\a-- @ !\a-2  ,Address:7...** 2  t . 2    2    :. 2  *  2  *  . 2  X  2  X  :. 2    2    . 2    2    :. 2    :. 2  #  r :. 2  l :.l'- @ !\-- @ !\-2 c ,City: <' 2 c  :. 2 c   2 c   . 2 c *  2 c *  :. 2 c X  2 c X  . 2 c   2 c   :. 2 c   2 c   . 2 c   .2 c #  rState: 7.. 2 c   r 2 c   r :. 2 c @  r 2 c @  r . 2 c n  r 2 c n  r :. 2 c  r 2 c  r . 2 c  r 2 c  r :. 2 c  r :.2 c lZip:3. 2 c )l : 2 c @l 2 c @l . 2 c nl 2 c nl :. 2 c l 2 c l . 2 c l 2 c l :. 2 c l 2 c l . 2 c &l .l'- @ !\ -- @ !\ -2 ,  Telephone: 4....... 2   2   :. 2   2   . 2 >  2 >  :. 2 l  2 l  . 2   2   :. 2   :.2 #  Fax: 3.* 2   2   . 2   2   :. 2 8   2 8   . 2 f   2 f   :. 2   2   . 2   .- @ !\u -- @ !\u - 2  ,{ .{' 2  u  . u' 2  #  r .r ' 2  l .l'- @ !\ -- @ !\ -- b2 { s:pThe company listed above wishes to provide an unrestricted3..*.E...**.....*.<*..*...*.......**..:2 {  p educational grant for support ...*........*....p'- 2  pfor the above ......*. 2 p- A2 $pnamed CME activity in the amount of:..E..<D7.***....E....- 2 Ep .p'@ Arial- 2 Zt$ 8- 2 t 2 t :3 2 t 2 t 3 2 t 2 t :3 2 Gt 2 Gt 3 2 zt 2 zt :3- 2 t :8t' 2 @ :8'- @ !- -- @ !- p-- @ !- p-- @ !- t-- @ !- -- @ !- -- @ !- -- @ !1 -- @ !1 p-- @ !1 -- @ !1 -- 2 9 ,{ :.{' 2 9 u  :. u' 2 9 #  r :.r ' 2 9 l :.l'- @ ! -- @ ! p-- @ ! p-- @ ! t-- @ ! -- @ ! -- @ ! -- @ !\ -- @ !\ - 2 ,{ :.{' 2 u  :. u' 2 #  r :.r ' 2 l :.l'- @ !\K -- @ ! -- @ ! -- @ !z -- @ ! u-- @ !} y-- @ ! -- @ !~ -- @ ! l-- @ !{ p-- @ !\K -- @ ! -- @ ! - 2 , :-'- 2 Z , :1'-+2 ,NOTE TO PROGRAM REPS: BH7=7H=BHHB?MB===- @ !  ,- -q2 D Please remember to add your signature and date on the second page.7..*..G.G......'..*...............*.*....... 2 * :-'@ Arial- 2 `  CONDITIONSBHBB8HB= 2 `   :3-2 , 1.. 2  :- +2 XStatement of Purpose: 7..J.3373 33..-2   CME is fo<E7*.2 ePr scientific and educational purposes only and will not promote any products or **..*......*........*.*..'...;....G....'....**.-=2 PX!services, directly or indirectly.*.)*.*..*'....*'- 2 P :1-2 , 2.. 2  :- b2 X:Control of Content & Selection of Presenters & Moderators:<33 33<33.3<7...3337 ...3. .<G33. .3 .-J2  * UCSF is responsible for the content and <<73*.*...*.....*.......C2 >X%selection of presenters and moderator*..*.....*...*...G.....t2 >Fs. Any commercial supporter, or its agents, will respond only to UCSF*7.'*.GG.*.*......*....*;.*......'.<<73 2 >-:-2 XQinitiated requests for suggestions of presenters or sources of presenters. UCSF ........**.*....*..*...*...*.*..*.*...*...*<<73-2  willA-72 f seek suggestions from other t*..+*....*..*.G...-t2 XFsources and will make the final decision on the presenter(s) selected.*..*.*...;G.+.......**........*...**..*..- 2 B  :1-2 , 3.. 2  :- D2 X&Disclosure of Financial Relationships:<..3.3 .333.3..<..33.33.-t2 9F UCSF will disclose to the audience any significant relationships as <<73;.**.*.........*...'*..*......*..*.*-z2 XJspecified by ACCMEs Essential Areas and Standards of commercial support. *..*...'7<<E7*7**...7..*...7.....*.*.GG.*.*....- 2   :1-2 , 4.. 2  :- .2 XPromotional Activities:7 3J333.9./..-G2 ( No promotional activities will be perm<...G.....*).*;....GR2 e /itted in the same room or obligate path as the .....*.G...G..........*..'-,2 Xeducational activity. ...*.....*)'- 2 > :1'-2 n, 5..- 2 n :/2 nXObjectivity and Balance:A3../-.33<..3..-2 nO UCSF will ensure that data regarding the commercial supporters products (or <<73;..*...............*.GG.*.*.....*....**.'2 XNcompeting products) are objectively selected and presented, with favorable and*.G........**.....*).'*..*.......*....;..).......>2  " unfavorable information and will ...)......G......;'-2 'Xeensure balanced discussion of prevailing information on the product(s) and/or alternative treatments...*......*...**.**.....).....G...........**........)...G..*- 2 ' :1'-2 , 6.. 2  :- )2 XLimitations of Data:3J.33.3<..-2 a^ UCSF will ensure, to the extent possible, disclosure of limitations of data, (e.g., ongoing <<73;..*......*....**...**.*...G...*............'- 2 Xr:s2 tEesearch, interim analyses, preliminary data, or unsupported opinion). .*..*...G...'*.*..G..'......*...........- 2 J  :1'-2 , 7.. 2  :- 82 XDiscussion of Unapproved Uses:<..3..333<3.33 3/.3<...-}2 oL UCSF requires that presenters disclose when a product under discussion is <<73....*....*...*.**.*.;........*.....**.**..*-J2 X*not approved for use in the United States.......)....*....<...7..*- 2 Q :1-2 , 8.. 2  :- 12 XOpportunities for Debate:UA333 33..3 <.3..-2 H q2 vDUCSF will ensure opportunities for questioning or scientific debate.<<73;..*.........*....*.....**..*.....- 2  :1@ Arial- -                         N@N Normal1$"B*CJOJQJ_HhmH sH tH b@b Heading 1)$$$d%d&d'd1$@&a$ 5OJQJT@T Heading 2$$ww1$@&a$56OJQJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List XOX normalstyle1$"B*CJOJQJ_HhmH sH tH @ @@ Footer  ! 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