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DIsclosure Form

Disclosure of Relevant Financial Relationships by Faculty & Planners of CME Activities

The intent of this disclosure is to allow the Kansas City Southwest Clinical Society (KCSWCS) the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its CME activities. All faculty and planners of KCSWCS-sponsored activities are expected to disclose to the KCSWCS any relevant financial relationships with any commercial interest that produces health care goods or services related to the content of the educational presentation in which they are involved.

Conflict of interest: Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

Commercial interest: 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: 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. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and his/her spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.

Acknowledgment Statement

By submitting this electronic form, I acknowledge and agree that my recommendations involving clinical medicine in this CME activity 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 referred to, reported or used in support or justification of patient care recommendations will conform to the generally accepted standards of experimental design, data collection and analysis. I further agree to disclose when discussion of an unlabeled use of a product or an investigational use not yet approved occurs during the course of the presentation.

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Kansas City Southwest Clinical Society

9229 Ward Parkway, Suite 280
Kansas City, MO 64114
Phone: 816.523.3383
Fax: 816.523.3393