MLI Disclosure Form

Step 1 of 9

About This Online Form

Medical 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 ineligible companies (formerly known as 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 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 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 24 months. 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), please complete this online questionnaire regarding any financial relationships for the last 24 months you may hold with ineligible companies.

Any individual who refuses to disclose their financial relationships will be disqualified from participating in the CE activity.

Acknowledgement

I have read the above information and agree to continue.

Project Partner

Project Initiative

ABOUT YOU

Please include your FULL NAME, CREDENTIALS, AND TITLES/AFFILIATIONS as you would like it printed online or in educational materials.
Example: John Q. Smith or John MiddleName Smith
Professor, University of Florida
Department Chair, Department of Oncology
Somewhere, FL

Name:

Please include your name as you would like it printed online or in educational materials.

Credentials

Title(s) and/or Affiliation(s)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Disclosure

Primary Email Address:

This email will be used to contact you regarding MLI projects.

Secondary Email Address:

Please include any secondary or alternate email address you use to communicate with MLI.

Office/Primary Phone #:

This phone number will be used to contact you regarding MLI projects.

Mobile Phone

This phone number will be used to contact you regarding MLI projects.

Do you have an administrative assistant or support personnel who should be included on communications from MLI?

Yes, I will include their information on the next page
No

AGREEMENT TO PARTICPATE IN ACCREDITED EDUCATION

It 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 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.

ATTESTATION

Agreement to Participate

I agree to adhere and abide by the above responsibilities and requirements listed above

I 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

Name

Date Completed

MLI Disclosure Form