EBAC _ EBAH Disclosure Declaration Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 7About this FormMedical Learning Institute Inc (MLI) is committed to providing high quality accredited continuing education (CE) to healthcare professionals, as individuals and teams, with a protected space to learn, teach, and engage in scientific discourse free from influence from commercial interests that may have an incentive to insert commercial bias into education. To that end, MLI abides by the Standards for Integrity and Independence in Accredited Continuing Education as well as the European Board for Accreditation of Continuing Education for Health Professions (EBAC(R)) and the European Board for Accreditation in Hematology (EBAH). This form is to collect information that is applicable to accredited CE across the health professions and are designed to: • Ensure that accredited CE serves the needs of the patients and the public; • Present learners with only accurate, balanced, scientifically justified recommendations; • Assure healthcare professionals and teams that they can trust accredited continuing education to help them deliver safe, effective, cost- effective, compassionate care that is based on best practice and evidence; • Create a clear, unbridgeable separation between accredited continuing education and marketing and sales; and • Identify any other potential or real conflicts of interest that may interfere with the presentation of accredited continuing education. In accordance with guidelines set forth by European Board for Accreditation of Continuing Education for Health Professions (EBAC(R)) and the European Board for Accreditation in Hematology (EBAH), Joint Accreditation for Interprofessional Continuing Education, including but not limited to, the Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE), and the American Nursing Credentialing Center (ANCC), Medical Learning Institute, Inc (MLI) has implemented a process whereby all speakers/faculty/presenters, authors, planners, content reviewers and others who have the potential to affect the content of accredited CE are required to disclose for themselves all financial relationships with ineligible companies within the last 36 months or anticipated in the 12 months ahead. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Financial relationships, or other financial benefits create a real, or apparent, conflict of interest which must be identified and mitigated prior to the commencement of the CE activity. The information listed on this form will be used to assess and mitigate any potential conflict of interest you may have and will be disclosed to the audience of the CE activity. In order to meet the expectations of not only of Joint Accreditation for Interprofessional Continuing Education(TM) (JA) but including the European Board for Accreditation of Continuing Education for Health Professions (EBAC(R)) and the European Board for Accreditation in Hematology (EBAH), please complete this online questionnaire regarding any financial relationships for the last 36 months as well as 12 months ahead that you may hold with commercial interests. Any individual who refuses to disclose their financial relationships will be disqualified from participating in the CE activity.Name: *Please include your name as you would like it printed online or in educational materials.Title(s) and/or Affiliation(s) *Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDo you have an administrative assistant or support personnel who should be included?Yes, I will include their information belowNoDate of Disclosure *Primary Email Address: *This email will be used to contact you regarding MLI projects.Office/Primary Phone #:This phone number will be used to contact you regarding MLI projects.Mobile PhoneThis phone number will be used to contact you regarding MLI projects.Administrative Assistant InformationIf you have an executive or administrative support who may assist you, please provide their name and contact information.Assistant Name *Assistant's Email *Assistant's PhoneNext Page What is a financial relationship? 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. A commercial interest is one whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products or services used by or on patients. IF in the last 36 months or if anticipated in the next 12 months, you or your spouse/partner have had no financial relationships with ineligible companies to disclose, select “I have no financial relationships with ineligible company(ies).” IF in the last 36 months or if anticipated in the next 12 months, you or your spouse/partner have or had a financial relationship(s) with an ineligible company(ies), select “I have/had one or more financial relationships with (an) ineligible company(ies). I will provide additional information on the following pages. DECLARATION OF FINANCIAL RELATIONSHIPS WITH INELIGIBLE COMPANIES IN THE LAST 36 MONTHS: *I or my spouse/partner HAVE HAD NO financial relationships with ineligible company(ies).I or my spouse/partner HAVE HAD ONE OR MORE financial relationships with ineligible companies. I will provide more information on the following pages.Previous PageNext PageEmployment or Ownership StatusI am an employee of another company who is defined as a commercial interest. *YesNoA commercial interest is any entity producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.. This may include a start up, small biotech company, or similar type of business.Company *Is this relationship ongoing?YesNoComments:I am an owner (in whole or in part) of a company who is defined as a commercial interest. *YesNoA commercial interest is any entity producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. This may include a start up, small biotech company, or similar type of business.Company *Is this relationship ongoing? *YesNoComments: Previous PageNext PageSTOCKS OR STOCK OPTIONSI have stocks or stock options to disclose.Yes, I have shares of stock.Yes, I have stock options.Yes, I have both shares of stock and stock options.No, I don’t own stock or stock options.Company or Companies – Shares of Stock *Please identify any and all shares of stock you may hold with publicly traded or privately held companies that are defined as ineligible companies. This may include a start up, small biotech company, or similar type of business. A commercial interest is any entity producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.Comments about Shares of Stock:Company or Companies – Stock Options *Please identify any and all stock options you may hold with publicly traded or privately held companies that are defined as ineligible companies. This may include a start up, small biotech company, or similar type of business. A commercial interest is any entity producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.Comments about Stock Options:Previous PageNext PageADDITIONAL CATEGORIES OF FINANCIAL RELATIONSHIPSBelow you can provide more information about any of the following roles: speaker/presenter, consulting/advisory roles, research funding (including contracted research), royalties or patent beneficiary. Include all relationships that are current or have expired in the last 36 months. If the relationship has ended, please add “(concluded)”. Example: AbbVie (concluded) I am or have been a consultant, advisor, or part of a speakers' bureau.YesNoPlease include any and all companies for whom you have served as an a consultant , advisor or speakers' bureau: *Is this/Are these relationship(s) ongoing? *YesNoComments Consultant or Advisor RoleI have received research support (grants).YesNoPlease include any and all companies where you are a principal investigator of a research grant or other financial support for research: *Is this/Are these relationship(s) ongoing? *YesNoComments about Research SuppportI have received royalties or financial benefits from a patent.YesNoPlease include any and all companies where you may have received royalties or compensation from a patent: *Is this/Are these relationship(s) ongoing? *YesNoComments about Royalties or PatentsI have received honoraria for educational activities (CE/CME/CPD)YesNoPlease include any and all companies where you may have received honoraria for educational activities: *Is this/Are these relationship(s) ongoing? *YesNoComments about Honoraria PaymentsPlease Describe Any Other Financial or Non-financial Benefit or Compensation Not Already ListedPlease add any other relationships with ineliible companies not addressed above. This may include: – other ownership interests other than options, stocks, or bonds. – compensation for serving an executive role in a company. – proceeds from selling proprietary goods (eg, supplements) on your website.I have additional information to share but I will provide separate documentation below.Click Here to Upload File(s)I don’t need to attach anything to this form.Disclosure Documents or Additional Information Click or drag files to this area to upload. You can upload up to 3 files. Previous PageNext PageAGREEMENT TO PARTICPATE IN ACCREDITED EDUCATIONIt is the responsibility of CE providers to facilitate engagement in appropriate discussions and debates regarding new and evolving topics. However, there must be clear delineation between valid content and that which is speculative or controversial. MLI will assist discussion but will not allow advocating for or promoting any practices that are not (or not yet) adequately supported by evidence, current science, and sound clinical reasoning. To ensure the quality of our CE activities, please attest and sign below to confirm your agreement to abide by the Policies of European Board for Accreditation of Continuing Education for Health Professionals (EBAC(R)), the Joint Accreditation for Interprofessional Continuing Education™, the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) as well as with the spirit of the PhRMA Code, AdvaMed Code of Ethics, FDA Guidance, Department of Health & Human Services Office of Inspector General (HHS OIG), as well as MLI policies. I have disclosed all financial relationships and understand that this information will be disclosed to learners. Should any changes occur that impact these financial relationships, I will notify MLI. I agree to comply with the following content validity requirements: All recommendations for patient care in accredited CE will be based on current science, evidence, and clinical reasoning while giving a fair and balanced view of diagnostic and therapeutic options. All scientific research referred to, reported, or used in support or justification of patient care recommendations that conform to the generally accepted standards of experimental design, data collection, and interpretation. Accredited CE should not advocate for unscientific approaches to diagnosis or therapy or promote recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients. I agree to disclose any unlabeled or unapproved uses of drugs or products referenced or discussed in accredited CE. In the planning and/or discussion of specific health care products or services, I agree to use the scientific or generic names when referring to products. Should it be necessary to use a trade or brand name, I will use the trade names of all similar products or those within a class. All materials will not include any company logos, taglines, or marketing messages. I understand that this activity will be reviewed by peers prior to the CE activity occurring to ensure content is valid and meets the expectations of Joint Accreditation of Interprofessional Continuing Education™. I will not accept direct remuneration or gifts directly from any ineligible company or their agent(s), nor will I allow input from any ineligible company or their agent(s) regarding my participation in this CE activity. I understand that all payments and reimbursements must be made by the accredited provider or designated and authorized educational partner. I agree to ensure patient confidentiality requirements consistent with the Health Insurance Portability and Accountability Act (HIPAA). I will ensure that I have garnered the appropriate permissions from any third party for information or materials used in this CE activity. To the extent that copyrighted or trade secret materials are used, reproduced, or displayed, I have sought and received permission to use, reproduce, and/or distribute such materials from the copyright owner. I agree to allow any handout materials (eg, slides) that may be distributed to learners electronically in a PDF format. Distribution may include email, downloads form a website or mobile app, or other mechanism. ATTESTATIONAgreement to Participate *I agree to adhere and abide by the above responsibilities and requirements listed aboveI attest that the information included above is complete and true. Should any financial relationships change (additions, endings, or other changes), I will inform MLI as soon as is practicable and possible. *This disclosure is complete and the information provided is correct and true.Signature Clear Signature Date Completed *Name *Previous PageNext PageUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Thank you! MLI recognizes and honors the time and effort spent completing and sharing this information with us. We look forward to a successful collaboration with you! MEDICAL LEARNING INSTITUTE INC www.mlieducation.org Previous PageFINISHED!
