American College of Allergy, Asthma & Immunology CME Compiled Disclosure & Resolution of Conflicts of Interest (COI) <Insert Joint Provider Name>│ <Insert Meeting Title> <Insert Meeting Date(s)> │ <Insert Meeting Location> Deadline: Return the completed form no later than 3 months prior to the start of the activity. Does a Activity Role Played What was Received Is there a How was the COI Commercial potential Role (e.g. Employee, Independent (e.g. Salary, Royalty rights, financial resolved? Name Interest conflict of Contractor, Consulting, Honorarium, Consulting fee, (e.g. Presenter, relationship to (list a minimum of 1 from interest (COI) Speaking/Teaching, Advisory or Stocks, Contracted Research, Company Name Moderator, the full listing below) Disclosure? Board Committee member, etc.) Intellectual Property, etc.) exist? Planner, etc.) 1.Speaker 1.Honorarium Example: Speaker & YES NO 1.Ethicon YES NO Limit the sources, Limit 2.Advisory Committee member 2.No financial incentive Dr. Thomas Jones Planner 2.Medtronic the content YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Signature of Program Chair/Planning Committee Date Printed Name
American College of Allergy, Asthma & Immunology CME Compiled Disclosure & Resolution of Conflicts of Interest (COI) <Insert Joint Provider Name>│ <Insert Meeting Title> <Insert Meeting Date(s)> │ <Insert Meeting Location> Deadline: Return the completed form no later than 3 months prior to the start of the activity. Name Activity Role (e.g. Presenter, Moderator, Planner, etc.) Is there a financial relationship to Disclosure? Commercial Interest Company Name Role Played (e.g. Employee, Independent Contractor, Consulting, Speaking/Teaching, Advisory or Board Committee member, etc.) What was Received (e.g. Salary, Royalty rights, Honorarium, Consulting fee, Stocks, Contracted Research, Intellectual Property, etc.) Does a potential conflict of interest (COI) exist? How was the COI resolved? (list a minimum of 1 from the full listing below) Example: Dr. Thomas Jones Speaker & Planner YES NO 1.Ethicon 2.Medtronic 1.Speaker 2.Advisory Committee member 1.Honorarium 2.No financial incentive YES NO Limit the sources, Limit the content YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Signature of Program Chair/Planning Committee Date Printed Name