Due Upon Receipt Faculty Name: * Presentation Title: * CME Activity: Activity Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202520262027 Your role in this CME: * Check all that apply Presenter Content Reviewer Course Director Moderator Planning Committee Consistent with ACCME Standards for Integrity and Independence in Accredited Continuing Education requirements, all relevant financial relationships must be appropriately mitigated prior to the start of the educational activity to prevent commercial bias and ensure the independence of educational content. This attestation is required for faculty participating in an accredited CME activity who have disclosed a relevant financial relationship with an ineligible company when educational content is unable to be reviewed. Information regarding relevant financial relationships will be disclosed to learners. Attestation Statements * I agree to the following regarding my participation in this CME activity: I attest that I will present balanced, evidence-based, and unbiased therapeutic options and will not favor, promote, or market any products, devices, drugs, or services from the ineligible company with which I have a financial relationship or any other ineligible company. I attest that all clinical statements, case discussions, and recommendations will be based on current, evidence based, peer reviewed literature. I attest that all scientific research referred to, reported, or used in CME in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection, and analysis. I attest that I will use generic names for medications/devices to the extent possible. If I need to use trade names, those from several companies will be used when available, and not just trade names from any single company. I attest that I will not use slides, graphics, logos, data, or materials created by or funded by an ineligible company. I attest that if I discuss unlabeled or investigational uses, I will clearly identify them and provide supporting evidence. I attest that I will not accept honorarium, travel expenses, in-kind contributions, or any other support from any ineligible company in connection with this activity. I attest that I will comply with all HealthPartners CME mitigation requirements, including potential review of course content and presentation monitoring by the CME office, course chair, moderator, and/or course coordinator. Initials for Electronic Signature * Today's Date * Leave this field blank
