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:

2. conflicts of interest to report.
Conflict of Interest Disclosure <First Name> <Last Name>, <Degree>
Has no real or apparent
conflicts of interest to report.

3. Please Remember
While every faculty member may perceive they are providing a presentation unaffected by any relationships they are disclosing, please do not include any wording to that effect (eg- Dr X perceives no conflict of interest with the presentation…).  The major reason for this is the responsibility for making the assessment of whether or not COI exists rests with PIM, not with the faculty member. To make this statement on a slide shown to the audience could be misleading both in fact (we might have decided there is a COI), and with regard to our fulfilling our responsibilities as a provider.
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.