1. Conflict of Interest Disclosure <First Name> <Last Name>, <Degree>
Salary:
Royalty:
Receipt of Intellectual Property Rights/Patent Holder:
Consulting Fees (e.g., advisory boards):
Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers’ bureau):
Contracted Research:
Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds):
Other:
This slide is for the authors who have conflict of interest to disclose.

2. Please Remember If you have COI:
When listing relationships reported by faculty on this slide, do not clump them all together.  The ACCME/ANCC/ACPE requirement is to disclose the type/nature of relationship and company, which would mean you could list consulting arrangements and group all of the companies disclosed for that relationship, and then speakers’ bureaus together, and so on.  
However, you should not group “stock owner, consulting, speakers’ bureau, and contracted research” together and then list all companies disclosed.  The nature of those relationships is different, and the learner should know about each in turn.