.

Anesthesiology CME

CME Financial Disclosure

Please e-mail your complete presentation to Anesthesiology CME Program Coordinator Deborah Nelson Rouse at deborah.nelson@vanderbilt.edu. Speakers receiving financial compensation must also complete a W9 form. Click here for a fillable W9 form and return to Deborah Nelson Rouse at deborah.nelson@vanderbilt.edu.

 

Name with degree designation(s):
Email address:
Phone number:
Institutional affiliation:
Date you are presenting:
 

 

PRESENTATION TITLE & LEARNING OBJECTIVES
Please provide your title and three (3) learning objectives for your presentation completing this statement:  "After participating in this CME activity, participants will be able to describe and discuss..." 

 

Please insert your Anesthesiology   
Grand Rounds presentation title   
and learning objectives here:  



I have no financial relationships to disclose. Click here to complete the Final Section.
I or my spouse/partner have/had a financial relationship relative to my involvement in this CME activity.  Complete the Commercial Interest section and then complete the Final Section.

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.  Non-profit or government organizations and non-healthcare related entities are excluded from disclosure.

  • As part of the ACCME requirements, the information being requested relates to your role in influencing the content for Anesthesiology Grand Rounds or any other CME-related program sponsored or co-sponsored by the Vanderbilt Department of Anesthesiology.

  • Please indicate any financial relationship in any amount that you or your spouse/partner have/had within the last twelve (12) months that relates to the content for Anesthesiology Grand Rounds or any other CME-related program sponsored or co-sponsored by the Vanderbilt Department of Anesthesiology.


 I or my spouse/partner have relationships with the following company (ies)

as a consultant


for a research grant


for speaker fees

as a shareholder


as an employee






 


FINAL SECTION

By entering today's date in the space provided below, you are agreeing to the following terms:

 

  • You will inform Anesthesiology Grand Rounds or any other CME-related program sponsored or co-sponsored by the Vanderbilt Department of Anesthesiology participants if you discuss or reference an unapproved, un-labelled or investigational use of a therapeutic agent or biomedical device.

  • That the information you use in your presentation is based on the educational needs of physicians, rigorous scientific evidence from research or  your clinical experience and was developed independent of commercial interests.

 

Enter today's date here

 

 


 

This page was last updated December 6, 2010 and is maintained by