PUT YOUR COURSE NAME HERE and COURSE DATE HERE   
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Important: Per the Accreditation Council for Continuing Medical Education (ACCME), persons who fail to complete this form are not eligible to be involved.
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(select all that apply)
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mm-dd-yyyy
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Disclose all financial relationship(s) regardless of relevance to the content of the activity. Include those that you have or have had within the past 24 months. List the entities producing, marketing, selling or re-selling, or distributing health care products, used by or on patients. Check one
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Choose all that apply:
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Name of Ineligible Company(s)
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List the Name of Company(s)
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List the Name of Company(s)
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List the Name of Company(s)
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List the Name of Company(s)
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List the Name of Company(s)
Disclosure of Off-Label and/or Investigational Uses     
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If, at any time, during my education activity, I discuss an off-label/investigative (unapproved) use of a commercial product/device, I understand that I must provide disclosure of that intent.
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Presentation(s) Content: Faculty Responsibility     
  • The Presenter/Faculty acknowledges that they are responsible for obtaining all necessary copyright permission(s) for any third party materials incorporated into their presentation. Upon request Presenter agrees to furnish copies of said permission(s) to the Mayo Clinic CE provider. The Presenter is responsible for all fees, royalties, and other charges for the use of such materials. The Presenter, if not a Mayo Clinic employee, shall indemnify Mayo Clinic for all damages, costs and expenses, including attorneys’ fees, incurred by Mayo Clinic as a result of a violation of this paragraph.
  • CE must give a balanced view of therapeutic options. Use of generic drug names contributes to impartiality. If your CE educational material or content includes trade names; the trade names from several companies should be used where available, not just trade names from a single company.
Signature and Verification     
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I attest that the information is accurate. Accept this as my signature.
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Common Terminology     

Non-Eligible Companies
The ACCME defines an “in-eligible company” as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. 

Financial Relationship(s)
Financial relationships are those relationships in which the individual benefits by receiving a 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 from an ineligible company. Financial benefits are usually associated with roles with ineligible companies 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 from which remuneration is received, or expected.

Off-Label Use and/or Investigational Uses - FDA Statement
Some drugs or medical devices demonstrated have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical devices he or she wishes to use in clinical practice.

“Off-label” uses of a drug or medical device may be described in CE activities so long as the “off-label” use of the drug or medical device is also specifically disclosed (i.e., it must be disclosed that the FDA has not cleared the drug or device for the described purpose). Any drug or medical device is being used “off-label” if the described use is not set forth on the product’s approval label.