Section 1. Purpose of Disclosure.

Name:

Title of Activity:

Primary Role in SGO Activity:

In my role I represent the following (check all that apply):

Content Expert

Target Audience

Adult Learning Expert (Faculty in an Academic Institution)

Accreditation/Compliance Expert (experience developing CME and/or CEU compliant programs)

Education planner

Section 2. Financial Disclosure.

In order to assure the highest quality of continuing medical education (CME) programming, SGO requires individuals (including their spouse/life partner) who have the opportunity to affect the content of a CME activity to disclose any financial relationship(s) with a commercial interest. Note: This is mandatory to participate in the CME activity. Disclosures are made in written form prior to the start of the CME activity and communicated, in writing and verbally, to the learner. All financial relationships will be resolved prior to the start of the activity through the SGO Conflict of Interest Resolution Policy.

A Financial Relationship exists when an individual (or their spouse/life partner) benefits from a relationship with a commercial interest by receiving a financial benefit, including, but not limited to the selections below. Any Financial Relationship which has occurred within the past twelve months must be disclosed.

On Behalf of You and Your Spouse/Partner Check One of the Boxes Below:

We have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

The commercial entities with which we have relationships do not produce market, re-sell or distribute health care goods

or services relevant to the content I am planning, developing, or presenting for the activity.

We disclose the following financial relationships with commercial entities producing marketing, re-selling, or distributing health care goods or services relevant to the content I am planning, developing or presenting:

We disclose the following financial relationships with commercial entities producing marketing, re-selling, or distributing health care goods or services relevant to the content I am planning, developing or presenting:
Company	Type of Relationship*	Content Area (if applicable)

*Types of relationships include, but are not limited to, board membership, consulting, grants, honoraria/reimbursement, speakers’ bureau(s), and stockholder/shareholder.

Section 3. SGO Policy.

I have read and fully understand the SGO/Presenter Guidelines. I agree to act in accordance with these guidelines.

I have read and fully understand the potential repercussion(s) of violating the SGO/ACCME Accreditation Presenter Guidelines, per the SGO Biased Presentation Policy.

Section 4. Attestations.

Please indicate your understanding of and willingness to comply with each statement below. They are based on requirements of the ACCME. If you have any questions regarding your ability to comply, please contact the course director as soon as possible. (A=Agree, D=Disagree, N/A=Not applicable)

A	D
On this form I have disclosed all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.
The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest.
Content for this activity, including any presentation of therapeutic options, will be well balanced, unbiased, and to the extent possible, evidence-based. Opinions that are not supported by evidence, or are supported by limited or preliminary evidence will be so identified.
I have not and will not accept any honoraria, additional payments or reimbursements for this CME activity beyond that which has been agreed upon directly with the course director/SGO.
A	D	N/A
If I am presenting at a live event, I understand that a CME monitor may be attending the event to ensure that my presentation is educational, and not promotional, in nature. If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research I refer to, report, or use in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.
For any drug/product discussed, the data must be objectively selected and presented, both favorable and unfavorable information about the drug/product must be fairly presented, and I will include information about reasonable alternative treatment options. Where there is a suggestion of superiority of one drug/product over another, this suggestion needs to be supported by evidence-based data.
If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.
If I am discussing any drug/product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA.
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.
If I am presenting research funded by a commercial company the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.

Section 5. Electronic Signature.

I have carefully read and considered each item in this form, and have completed it to the best of my ability. The information I have provided is accurate. I understand that this information will be disclosed to participants I agree to cooperate in any efforts to make this disclosure or to inform participants that I have nothing to disclose.

Electronic Signature:	Date: