Financial Relationship Disclosure Form
For more information, visit accme.org/standards.
As a prospective planner, faculty member or committee member, the ASMBS requires your help in protecting our learning environment from industry influence. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.
Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). If the financial relationship existed during the last 24 months, but has now ended, please check the required box. This will help the education staff determine if any mitigation steps need to be taken.
For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.
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.
- Examples of such organizations include:
- Advertising, marketing, or communication firms whose clients are ineligible companies
- Bio-medical startups that have begun a governmental regulatory approval process
- Compounding pharmacies that manufacture proprietary compounds
- Device manufacturers or distributors
- Diagnostic labs that sell proprietary products
- Growers, distributors, manufacturers or sellers of medical foods and dietary supplements
- Manufacturers of health-related wearable products
- Pharmaceutical companies or distributors
- Pharmacy benefit managers
- Reagent manufacturers or seller
- Examples of financial relationships include:
- Employee
- Researcher
- Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.
- Consultant
- Advisor
- Speaker
- Independent contractor (including contracted research)
- Royalties or patent beneficiary
- Executive role
- Ownership interest
- Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed.