SPEAKER DISCLOSURE FORM



Disclosure Form

Title of CE Program:

Presenter’s or Author’s Name:

□ Within the past 12 months I have had no actual or relevant financial relationships to create a potential conflict of interest in relation to this program.

□ Within the past 12 months I have had a financial interest, arrangement of affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this CE program.

Affiliation or Financial Interest Name of Organization(s)

Consultant

Family Member Employed by Organization

Governing Board

Grant/Research Support

Major Stock Shareholder

Other Financial or Material Support

Speakers’ Bureau

Signature Date

Pharmacy Society of Wisconsin

701 Heartland Trail, Madison, WI 53717

9200. fax 608-827-9292

Pharmacy Society of Wisconsin

Disclosure Policy

Definitions:

Commercial Interest: Any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Providers of clinical service directly to patients are not ‘commercial interests.’

Relevant Financial Interest: Financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Policy:

It is the policy of the Pharmacy Society of Wisconsin to insure balance and objectivity in all of its individually or jointly presented CE programs. All faculty providing any PSW CE program are expected to disclose any “relevant financial interests” that may have a direct bearing on the subject matter of the continuing education program.

Individuals need to disclose relationships with a commercial interest if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CE about the products or services of that commercial interest.

Disclosure pertains to financial relationships with commercial interests whose products or services are related to the subject material of the program topic.

The intent of this policy is not to prevent a speaker with relevant financial interests from providing a CE program. Rather it is intended that any potential conflict should be identified openly so that they may be resolved and that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

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