ACTIVITY REQUEST FORM - Adventist Health
Faculty Disclosure FormIt is the policy of California Medical Center to ensure balance, objectivity, independence, and scientific rigor in all CME activities. Anyone engaged in activity content development, planning, or presentation must complete this form. “A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.”Faculty Name:John Smith, M.D.Activity Title:“Activity Title Here”Activity Date:Friday, December 15, 2012- or - FORMCHECKBOX Enduring MaterialsRole in this activity: FORMCHECKBOX Presenter FORMCHECKBOX Author FORMCHECKBOX Course Director FORMCHECKBOX Moderator FORMCHECKBOX Other: DISCLOSURE FORMCHECKBOX Yes FORMCHECKBOX NoHave you (or your spouse/partner) had a personal financial relationship in the last 12 months with a commercial interest, as defined above, relating to the subject matter that will be discussed in this CME activity?If no, sign below. If yes, please list your relevant financial relationships below and sign mercial InterestNature of Relevant Financial RelationshipName of CompanyEmployee, grants/research support recipient, board member, independent contractor, stock shareholder (excluding mutual funds), speakers bureau, honorarium recipient, royalty recipient, clinical trials, holder of intellectual property rights, otherSignature: Date: ................
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