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Disclosure Form - UNCLCN Lecture Planning Committee Member


The UNC Lineberger Cancer Network extends its appreciation for your agreeing to take part in our annual Lecture Planning Committee. To help us serve healthcare professionals across North Carolina, we depend on your expertise to determine the most critical educational needs during this time.


Please take a few moment to complete this survey that asks for basic information as well as any financial disclosures with ineligible companies as defined by the ACCME.


If you have questions or concerns, please send an email to unclcn@unc.edu or call (919) 445-1000.







Financial Relationship: Any relationship which benefits you financially.

 

Financial relationships include grants where the money goes to your organization, if you are the Principal Investigator. Financial relationships must be reported even if they have ended; in such cases, the end date should be noted in the Disclosure Grid.

 

Ineligible Company: Companies that are ineligible to be accredited in the ACCME System are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Ex: pharmaceutical companies, device manufacturers.

 

Eligible organizations include hospitals, physician practices, diagnostic labs that do not sell proprietary products, education companies (such as Elsevier or UpToDate), insurance companies, software companies (including electronic medical record companies), and government agencies. If you are uncertain about the eligibility of an organization, list it on the Disclosure Grid.


Enter the Name of Ineligible Company

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.

Enter the nature of the financial relationship

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. 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.

Has the relationship ended?

If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column.

                     Company                   Relationship Provide date if ended
Mitigation
The UNC Lineberger Cancer Network takes steps as appropriate to maintain the integrity of the educational opportunities from financial bias and abides by the requirements established in the ACCME's Standards for Integrity and Independence in Accredited Continuing Education.

UNCLCN holds the right to take the following steps as needed depending on your input above:
  •  Request recusal or remove from controlling aspects of planning and content with which there is a financial relationship.
  • Request further peer review of planning decisions by persons without relevant financial relationships on your suggestions.
  • Request attestation or further information regarding the aspects of your financial relationships to determine relevance to the topic or content in question.



Signature

I have carefully read and considered each item in this form and have completed it to the best of my ability.



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