A MERICAN ACADEMY OF SLEEP MEDICINE DISCLOSURE AND RESOLUTION

PREFACE NORTH AMERICAN NUMBERING COUNCIL (NANC) FUNCTIONAL REQUIREMENTS SPECIFICATION
RESOLUTION (A11) PAGE 3 OF 4 AMERICAN MEDICAL
RESOLUTION 904 (I06) PAGE 2 AMERICAN MEDICAL ASSOCIATION

0 COMITÉ INTERAMERICANO CONTRA EL TERRORISMO (CICTE)
0 ORGANIZACION DE LOS ESTADOS AMERICANOS CONSEJO
0 X II INTERAMERICAN CONFERENCE OF OEASERKXII121

American Academy of Sleep Medicine

A merican Academy of Sleep Medicine

Disclosure and Resolution of Conflicts of Interest in CME Educational Activities

As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Academy of Sleep Medicine must ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All product developers, planners, speakers, and chairs are expected to disclose any relevant financial interest or other relationships relevant to the topic of the presentation held by the individual or members of their family over the preceding twelve months with (l) the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services, (2) with any commercial supporters, (3) any off-label or investigational uses of products. The individual is also required to disclose if he/she has no relationship(s) with any manufacturer(s), product(s) or service(s). The ACCME also requires product developers, planners, speakers, and chairs to resolve any conflicts of interest. Therefore, if you have relevant conflicts, you are asked to declare that you will recuse yourself from decision-making having to do with the conflict and/or reference the best available evidence in your presentation/paper/product and to demonstrate this by providing 2-3 citations that you will refer to.

Educational Product

Your Name:  

Your Role:  

Product Title:  

Question 1:

Each product developer/planner/speaker/chair must disclose a financial interest or other relationship held by the individual or members of their family with commercial supporter(s) or with the manufacturer(s) of commercial product(s)/service(s) over the preceding twelve months that is relevant to the topic of the presentation. If you do not have a financial interest or relationship to disclose, please write none on the line.

Check here if you have nothing to disclose and skip to Question 3.

Consultant:

Grant/Research Support:

Speakers’ bureau:

Investigational Device/Drug:

Stock/shareholder:*

Other financial/material support:

Salary:

Royalties:

Intellectual Property Rights:

*excluding diversified mutual funds

Question 2:

If any financial interest or other relationship has been listed above, please provide 2-3 citations that are referenced in the presentation that provide the best evidence in support of the topic:

Question 3:

I agree that I have not received financial support from any manufacturer of commercial products/services to participate in the development of this product.

Question 4:

I agree that the best available evidence was referenced in the development of this product.

Signature Date

Print Name (please print legibly)

Check this box to represent an electronic signature:

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Office Use Only

I have reviewed the above COI form and agree that the planner, developer, presenter, or chair either has no relevant conflicts of interest or has established a plan to resolve them

Name: Date:

Page 1 of 2 American Academy of Sleep Medicine, Adopted 4/03/2005

1 ORGANIZACION DE LOS ESTADOS AMERICANOS
15 C OMISIÓN INTERAMERICANA DE MUJERES COMITÉ
2 AGRES 2141 (XXXVO05) PROGRAMA INTERAMERICANO

Tags: academy of, american academy, sleep, merican, resolution, medicine, academy, disclosure