Faculty/Planner Letter of Agreement Between the ACCREDITED PROVIDER

and

If you are giving a presentation, please complete a TITLE AND OUTLINE for each presentation. If you are a planner, sitting on a panel, moderating, author, or have any other roles, please SKIP to the Agreement
Section.

Agreement:

This letter is written to affirm an agreement between CMEsolutions and Faculty listed above, in regards to the aforementioned CME Activity. The conditions of this agreement are outlined below, and all parties agree that:

1. Statement of Purpose: This activity is for scientific and educational purposes only and will not promote specific products, directly or indirectly. The activity will be developed in a cooperative effort with CMEsolutions maintaining full control over all aspects of the program and assuring compliance with the ACCME Criteria, Standards for Commercial Support: Standards to Ensure Independence in CME Activities, and the ACCME Policies, the AMA Physician Recognition Award and Credit System and anyknownrelevant FDA or AMApolicies, ACPEStandards and CMEsolutions’ mission and policies.
2. Disclosure of Financial Relationships: The audience will be informed of the existence of any financial support of the program. This support will also be recognized, wherever possible, on brochures prepared for the program. At the beginning of the program, the audience will be informed of the existence of any relevant financial interest and/or other relationship(s) [e.g., employee, consultant, speaker's bureau, grant recipient/research support, etc.] a faculty member has to include the following information: The name of the individual, the name of the ineligible company, the nature of the relationship the individual has with each ineligible company. No employee or owner of ACCME-defined ineligible company will be permitted to have control over content of the activity.
3. Involvement in Content: There will be no "scripting" or targeting of content for emphasis or direction by any ineligible company or its agents.
4. Ancillary Promotional Activities: No promotional activities will be permitted in the same room or obligate path as the educational activity. No product advertisements will be permitted in the educational activity.
5. Objectivity & Balance: CMEsolutions will ensure that data regarding an ineligible company products (or competing products) are objectively selected and presented, with favorable and unfavorable information and balanced discussion of prevailing information on the product(s) and/or alternative treatments fairly represented. Trademarks and brandnames are prohibited.
6. Limitations on Data: When known, CMEsolutions will ensure, tothe extent possible, meaningfuldisclosureoflimitations on data and other information that is presented in the program - e.g. ongoing research, interim analysis, preliminary data, orunsupported opinion or assumptions.
7. Discussion of Unapproved Uses: CMEsolutions will require that the Faculty disclose when a product is not approved in the United States forthe use under discussion.Disclose any "unapproved" off-label usage.
8. Educational Methods: The Faculty shall use a method of delivery that shall allow for and encourage active participation and involvement on the part of the participants. During live activities, the Faculty shall provide for meaningful opportunities for discussionor scientific debate.
9. Clinical Content: All recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for the indications and contraindications in the care of patients. HIPPA laws are to be followed.
10. Sponsor Use of Contributed Funds: CMEsolutions shall pay the Faculty honoraria from the educational grant. No other funds from any ineligible company will be paid to the Faculty.
11. Program Records of Live Meetings: Videotapes, audiotapes, or other forms of recording media shall not be made without
    the prior written consentof CMEsolutions.
12. Scientific Research: All scientific research referred to must conform to the generally accepted standards of experimental design, data collection,and analysis and must promote improved patientcare. All copyright laws must be followed.
13. Withdrawal of Credit: If the ACCME Criteria, Policies, and Standards for Commercial Support are not followed, CMEsolutions reserves the right to withdraw CME credit designation.

CMEsolutions Policy on Honoraria and Reimbursement of Expenses for Planners, Teachers, and/or Authors

• CMEsolutions makes all decisions regarding the disposition and disbursement of any ineligible company support.
• CMEsolutions accepts no advice or services concerning teachers, authors, or participants, or other education matters, including content, from an ineligible company as condition of contributing funds or services for any CME activity. No payments will be accepted from any ineligible company for presenting.
• All terms, conditions, and purposes of any ineligible company support are documented in a signed agreement between the ineligible company and CMEsolutions and may be signed by any joint providers.
• Each ineligible company agreement specifies the ineligible company that is the source of support.
• CMEsolutions has written policies and procedures governing honoraria and reimbursement of out-of- pocket expenses for planners, teachers, and authors.
• CMEsolutions pays all honoraria or reimbursement of out-of-pocket expenses directly to any teacher or author unless arranged in advance with Joint Provider.
• CMEsolutions’ written policies and procedures prohibit any other payments to the director of any activity, planning committee members, teachers or authors, joint provider, or any others involved with the supported activity.
• CMEsolutions allows teachers or authors listed on the agenda as facilitating or conducting a presentation or session to participate in the remainder of an educational event as a learner but will be reimbursed for expenses and honoraria for their teacher or author role only.
• CMEsolutions does not allow social events or meals at CME activities to compete with or take precedence over the educational events.
• CMEsolutions does not use any ineligible company support to pay for travel, lodging, honoraria, or personal expenses for non- teacher or non-author participants of any CME activity.
• Expenses of teachers or authors are paid for their teacher or author role only when they are a participant of a CME activity.
• All ineligible company support funding is accurately documented as to receipt and expenditure and copies are made available for the ineligible company.

Faculty/Planner Disclosure Form, below, to be completed by all Planners, Faculty, or Others who may control content.

As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME) and the Accreditation Council for Pharmacy Education (ACPE), CMEsolutions must ensure balance, independence, objectivity, and scientific rigor in all individually provided or jointly provided educational activities. All faculty, planners and directors involved in an accredited activity are expected to disclose any relevant financial relationships with any ineligible company in any amount occurring within the past 24 months.

As a proposed planner or faculty member, we ask your help in protecting our learning environment from industry influence. Please complete the following:

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

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. All financial relationships should be disclosed regardless of the potential relevance of each relationship to the education.

In the past 24 months, have you had any financial relationships with any ineligible companies.
If you marked NO, please proceed to Signature/Attestation below.

Declaration of Commercial Interest

Nature of Relevant Financial Relationship(Please include all those that apply)
For each section follow these guidelines:

1) Enter the name of the Ineligible Company
An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients

2) Enter the Nature of Financial Relationship
Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

3) Has the Relationship Ended? Please answer simply YES or NO.
If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help the education staff determine if any mitigation steps need to be taken. 

Relationship #1

Relationship #2

Relationship #3

Relationship #4

Relationship #5

SIGNATURE/ATTESTATION