Preceptors

Conflict Of Interest

Conflict of Interest

In association with which resident is this form being submitted?
* Please note, you may need to submit this form multiple times, once for each resident that you are associated with.
Resident(s):

  • All continuing pharmacy education (CPE) activities should provide for an in-depth presentation with fair and full disclosure and equitable balance. Appropriate topics and learning activities shall be distinguished from topics and learning activities which are promotional or appear to be intended for purpose of endorsing either a specific commercial drug or other commercial product (as contrasted with the generic product/entity and its contents or the general therapeutic area it addresses), or a specific commercial service (as contrasted with the general service area and/or the aspects or problems of professional practice it addresses).
  • Commercial interest is defined as any proprietary entity producing health care goods or services, with the exception of non-profit or government organizations and non-health care related companies.
  • Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the CPE educational material or content includes trade names, where available trade names from several companies should be used, not just trade names from a single company.
  • An individual must disclose to learners any relevant financial relationship(s) prior to the beginning of the educational activity.
  • Disclosure should be described in the slide presentation, usually the second slide (if live presentation) or in any handout.
  • For an individual with no relevant financial relationship(s) the learners must be informed that no relevant financial relationship(s) exist.
  • If there is a relevant financial relationship, the conflict must be resolved prior to the activity.
  • Disclosure due to a relationship with a commercial interest is required if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CPE about the products or services of that commercial interest.
  • Financial relationships are those relationships in which the individual benefits by receiving salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected.
  • ACPE considers relationships of the person involved in the CPE activity to include financial relationships of a spouse or partner.
  • All individuals involved in a activity must sign a conflict of interest declaration, including those on a planning committee.
  • Anyone who refuses to sign a conflict of interest declaration may not be involved in the activity.
PART1: TO BE COMPLETED BY PARTICIPANT (read ACPE guidlines on non-commercialism)

(salary, royalty, intellectual property, ownership interest, or other financial benefit)
(employment, independent contractor, consulting, speaking and teaching membership, advisory committee, board member, other activities)

I understand that by typing my name in this box & today's date, I am affirming the truth of the above conflict of interest declaration. This serves as my signature of agreement.

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