Financial Relationship Attestation Form

Prospective Planner/Faculty Member,

You are required to complete this form if you have been contacted by the ASMBS Education Team due to the financial relationships that you disclosed on the Financial Disclosure form. This is one step in the mitigation process. Further action may be required.

The identification of relevant financial relationships does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity.

In accordance with the Accreditation Council for Continuing Medical Education (ACCME), ASMBS will choose a mitigation strategy for all persons with relevant financial relationships with an ineligible company who control the educational content of the educational activity.

Note: An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

For more information, visit accme.org/standard3.

Financial Relationship Attestation Form

• Name*
  First Last
• Email*
• Meeting Disclosing For:*
• Date*
  MM slash DD slash YYYY
• Have you divested from your disclosed relationship?*
  • Yes
  • No
• Role: (e.g. Planner, Reviewer, Speaker, Author, Moderator, Panelist)*

• Required Agreements

  Place a check in the box by each of the statements below to indicate your understanding and willingness to comply with each of the following statements.
• Agree*
  • I attest that I will disclose all financial relationships that I have had in the past 24 months with ineligible companies to attendees at the podium prior to the beginning of the presentation. (This should always be the first slide of your presentation.)
  • I attest that I will provide a copy of presentation slides and/or presentation outline to ASMBS for review and approval before the presentation and meeting takes place.
  • I attest that I will not speak on, control content or provide input on CME activity content that is related to clinical applications of the research/discovery or clinical recommendations concerning the business lines or products of my employer.
  • I attest that I will offer a balanced view of therapeutic options, and that there will be no commercial promotion or use of brand names.
  • I attest that IF the presentation must include references to trade names, where available, trade names of products from several companies will be referenced instead of trade names of a single company.

• You must agree to all the above statements to submit this form.

• Attestation*
  • I attest that the above information is correct as of the date of submission.
• By clicking “submit”, you attest to the fact that you have read, and are in agreement with, Part 4 of the ASMBS CME Policy on Disclosure as provided here.
• Date of Submission
• This field is hidden when viewing the form
  Date Completed
• This field is hidden when viewing the form
  Applicant IP
• CAPTCHA

Submit