ࡱ> jli` Sbjbj .b8l| . (>>>H-------$/h1r-"""->>a.&&&"(>>-&"-&&Vn+@,> @M+}"(+ .,w.0.+Tm2"m2,m2, s ^& L!"""-- &."""" $    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      ________________________________________________________________________________ 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 the manufacturer of the 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 mechanisms have been identified to resolve conflicts of interest. Please check all that apply: Presenter/Authors  FORMCHECKBOX  I will support my presentation and clinical recommendations with the best available evidence from the medical literature. See suggested sources of best evidence at  HYPERLINK "http://www.aafp.org/x3139.xml" www.aafp.org/x3139.xml.  FORMCHECKBOX  I will refrain from making recommendations regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, anOVWgh       .ɺɦgɗɺɦPgɺɦ,jvh)k>*CJOJQJU^JaJ1jh)k>*CJOJQJU^JaJmHnHu,jh)k>*CJOJQJU^JaJh)k>*CJOJQJ^JaJ&jh)k>*CJOJQJU^JaJh)k5CJOJQJ^JaJh)kCJOJQJ^JaJh)kCJOJQJ^JaJh)k5OJQJ^Jh)k5CJOJQJ^JaJOgh $&vx$If$a$LSS.02<>`"$&ռխ~i~[~F~~)jh)kCJOJQJU^JaJh)kCJOJQJ^JaJ)jbh)kCJOJQJU^JaJ#jh)kCJOJQJU^JaJh)k5CJOJQJ^JaJh)kCJOJQJ^JaJh)k>*CJOJQJ^JaJ1jh)k>*CJOJQJU^JaJmHnHu&jh)k>*CJOJQJU^JaJ,jh)k>*CJOJQJU^JaJ246bdLNjlnʵʠʑ|ʑhYB,j$h)k>*CJOJQJU^JaJh)k>*CJOJQJ^JaJ&jh)k>*CJOJQJU^JaJ)jh)kCJOJQJU^JaJh)k5CJOJQJ^JaJ)j8h)kCJOJQJU^JaJ)jh)kCJOJQJU^JaJh)kCJOJQJ^JaJ#jh)kCJOJQJU^JaJ)jLh)kCJOJQJU^JaJ$*8:NPR\^txĶiN7,jh)k>*CJOJQJU^JaJ4jh)k5>*CJOJQJU^JaJmHnHu/jh)k5>*CJOJQJU^JaJ h)k5>*CJOJQJ^JaJ)jh)k5>*CJOJQJU^JaJh)k5CJOJQJ^JaJh)kCJOJQJ^JaJh)k>*CJOJQJ^JaJ1jh)k>*CJOJQJU^JaJmHnHu&jh)k>*CJOJQJU^JaJ&468LNPZ\ݩzk^O=#jh)kCJOJQJU^JaJh)k>*CJOJQJ^JaJh)k5>*OJQJ^Jh)k5CJOJQJ^JaJh)kCJaJh)kCJOJQJ^JaJ1jh)k>*CJOJQJU^JaJmHnHu,jh)k>*CJOJQJU^JaJh)k5CJOJQJ^JaJh)kCJOJQJ^JaJh)k>*CJOJQJ^JaJ&jh)k>*CJOJQJU^JaJ$&`#$/IfK$gkd$$Ifl>++ t0+644 laq,-~qqqqaaq$$&`#$/Ifa$ $&`#$/Ifkd}$IfK$L$l^**  t 0644 l` ap    Ujq},-02V]`cʵʤʕʇʕvl]U]UQh)kh)kCJaJh)k5CJOJQJ^JaJh)kOJQJ^J h)k56CJOJQJ^JaJh)kCJOJQJ^JaJh)k5CJOJQJ^JaJ h)k5>*CJOJQJ^JaJ)jh)kCJOJQJU^JaJh)kCJOJQJ^JaJ#jh)kCJOJQJU^JaJ)j2h)kCJOJQJU^JaJ $$Ifa$ikd$$Ifl>++ 6`0+64 lacZZZZ $$Ifa$kd$$Ifl0j>+  t0+644 l` ap *+  $&(2468>@TVXbdfh|p[)j h)kCJOJQJU^JaJ)j h)kCJOJQJU^JaJ.jh)kCJOJQJU^JaJmHnHu)jp h)kCJOJQJU^JaJh)kCJOJQJ^JaJ#jh)kCJOJQJU^JaJh)k5CJOJQJ^JaJh)k5CJOJQJ^JaJh)kh)k5OJQJ^J6cZTT$If $$Ifa$kd $$Ifl0j>+  t0+644 l` ap68>fqhbb$If $$Ifa$kd\ $$IflFhj>+  t0+6    44 la|~,ززززuزز`زز)j;h)kCJOJQJU^JaJ)jh)kCJOJQJU^JaJ)j h)kCJOJQJU^JaJh)k5CJOJQJ^JaJh)kh)kCJOJQJ^JaJ.jh)kCJOJQJU^JaJmHnHu#jh)kCJOJQJU^JaJ)j h)kCJOJQJU^JaJ qhbb$If $$Ifa$kd $$IflFhj>+  t0+6    44 la>qhbb$If $$Ifa$kd$$IflFhj>+  t0+6    44 la,.0:<>@FH\^`jlnp?GHززززuزgXgNh)kOJQJ^Jh)k5CJOJQJ^JaJh)kCJOJQJ^JaJ)jJh)kCJOJQJU^JaJ)jh)kCJOJQJU^JaJh)k5CJOJQJ^JaJh)kh)kCJOJQJ^JaJ.jh)kCJOJQJU^JaJmHnHu#jh)kCJOJQJU^JaJ)jh)kCJOJQJU^JaJ>@Fnqhbb$If $$Ifa$kd'$$IflFhj>+  t0+6    44 la<@Z`0HIqggggYYYYY h$If^h $Ifkd$$IflFhj>+  t0+6    44 la HYZ[ijkDEF\]`aopqH0H2HNHŰŜvfQOU)jh)kCJOJQJU^JaJh)k0JCJOJQJ^JaJ,jh)k>*CJOJQJU^JaJh)k>*CJOJQJ^JaJ&jh)k>*CJOJQJU^JaJ)jmh)kCJOJQJU^JaJh)kCJOJQJ^JaJ#jh)kCJOJQJU^JaJh)k>*CJOJQJ^JaJh)k>*OJQJ^Jd/or research findings.  FORMCHECKBOX  I will recommend an alternative presenter for this topic for the planning committee s consideration.  FORMCHECKBOX  I will submit my presentation in advance to allow for adequate peer review.  FORMCHECKBOX  I will or have divested myself of this financial relationship. Planners  FORMCHECKBOX  To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias.  FORMCHECKBOX  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. Disclosure will be made to participants prior to the educational 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 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. 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[L[^[`LhH.q&n`Y         В        )khhcd    3 G H K _ s t w  @h|, , , @ (@4@HUnknownG: Times New Roman5Symbol3& : Arial5& zaTahoma"qh򖆱򖆣f " "wN!24d3qHX)?* ATTACHMENT A Anna Lincoln Anna Lincoln   Oh+'0 , L X d p|ATTACHMENT AAnna Lincoln FacultyDisclosureMergeV70105Anna Lincoln1Microsoft Office Word@@FE@}@}՜.+,D՜.+,< hp  UCSD"   ATTACHMENT A Title 8@ _PID_HLINKSAtAEhttp://www.aafp.org/x3139.xml  !"#$%&'()*+,-./013456789:;<=>@ABCDEFGHIJKLMNOPQRSTUVWXZ[\]^_`bcdefghkRoot Entry F0y2}mData 2e1Table?2WordDocument.bSummaryInformation(YDocumentSummaryInformation8aCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q