Faculty Agreement and Disclosure 2023

Name*
First Last Suffix
Email*
Cell Phone (or best contact number to reach you directly)*
This number will not be published. It is strictly used to communicate with you regarding the CE project.
ActivityTitle or Year:
Preferred Pronouns
Title and affiliation as you would like it to appear in announcements and materials

The purpose of this agreement is to outline the terms and conditions for faculty participating in KnowFully Medical Education (KME), under the branding of (CMEO), or Creative Educational Concepts, LLC (CEC) activities accredited for continuing education credit. The faculty named above has reviewed, understands, and accepts the responsibilities outlined in the enclosed confirmation letter and the following rules as required by KME in accordance with guidelines set forth by Joint Accreditation.

DISCLOSURE: All faculty must complete and submit financial relationships disclosure information prior to the presentation and declare that the information provided is complete and truthful to the best of their knowledge. Faculty must disclose the existence of any financial relationship they have with the commercial supporter, as well as any other ineligible companies as defined by the Standards for Integrity and Independence for Accredited Continuing Education. KME is responsible for identifying and mitigating any potential conflicts of interest in compliance with these Standards.

FREE OF COMMERCIAL BIAS: Faculty must prepare fair and balanced presentations that are valid, objective, scientifically rigorous, and free from commercial promotion. Furthermore, presentations should be based on the best available evidence and scientific methods generally accepted in the medical community. Personal anecdotes or recommendations based on your personal experience/clinical practice shall be mentioned only when evidence-based data is also cited to support the information being discussed.

USE OF GENERIC NAMES: Educational presentations must give a balanced view of therapeutic options. To contribute to this impartiality, faculty are asked to use generic names when referring to therapeutic treatment options. If trade names are used, then those of several companies should also be mentioned rather than only that of a single company.

UNLABELED OR OFF-LABEL (non-FDA-approved) USES OF PRODUCTS: Faculty must disclose to the audience when unlabeled use of a commercial product, or an investigational use not yet approved for any purpose, is discussed in their presentation. In addition to disclosure, faculty are also required to reference the best available evidence supporting the discussed usage.

COMMERCIAL SUPPORTER INFLUENCE: Faculty are not permitted to receive or accept any direct funds or gifts from the commercial supporter(s) of this activity as it relates to any KME accredited CE activity, nor should they be subject to direct input from a commercial supporter regarding the content of their presentation.

COPYRIGHTED MATERIALS: Faculty are responsible for obtaining permissions for all copyrighted materials used in their presentations. Faculty retain copyright in all original materials they contribute to the development of an educational activity.

IMAGE AUTHENTICITY: Faculty are responsible to ensure that all visual images provided to KME for use in this specific activity do not misrepresent or falsify the treatment outcomes described. Any modifications made to better represent the education must be explained and disclosed to the learner.

FACULTY RELEASE: Faculty agree to allow KME to re-issue the presentation as an enduring material in recorded/print format(s).

SELF-PROMOTION: Faculty must not promote or sell products or services that serve their professional or financial interests during any accredited CE activity.
KnowFully Medical Education (CME Outfitters, LLC or CE Concepts, LLC) will use your name to communicate information about this CME/CE activity. This may include but are not limited to email, outcomes survey emails, or added in social media posts about the activity. CME Outfitters' activities such as Breakfast Briefings, Instagram Takeovers, and Twitter Spaces are hosted natively on social media, so your name and likeness may be included not only during the activity itself, but also in pre-activity posts for the activity on our social media channels. CME Outfitters will use social media posts (eg, Twitter, Instagram, Linkedin, Facebook) to communicate this activity to an audience of learners. This may include campaigns to communicate information about your session and drive learners to participate. IMPORTANT NOTE: These efforts do not involve promoting or marketing any commercial product or company.
Permission to Use Name for CE/CME Activity Outreach?*
Do you agree to allow CMEO/CEC to use your name in the “From:” line of promotional emails pertaining to the activity you participate in as a faculty speaker, moderator or chair? (Your email address would NOT be included and email responses would NOT come to your email address)

Yes

No
Would you like to receive content to post on social media to help promote this activity?*

Yes

No
Note to CMEO/CEC
If you have questions or comments for CME Outfitters/CE Concepts staff about the use of your name as described above, please share them here.

Disclosure of Financial Relationships*
Please disclose any and all financial relationships you have had in the past 24 months with ineligible companies.
An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. For specific examples, visit https://accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ce/eligibility.

For each financial relationship, enter the name of the ineligible company. There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible entities. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education. You do not need to disclose financial relationships of your spouse or partner.

No, I do not have any financial relationships with ineligible companies. (click Continue button at bottom of page)

Yes, I have/had a financial relationship(s) with ineligible companies. (I will provide more information below)
If you have financial relationships, please provide additional information. Below are the most common types of relationships. If you wish, you may email additional disclosure information to facultyinfo@cmeoutfitters.com
Advisory Board:
Consultant:
Grants:
Research Support:
Speakers Bureau:
Stock Shareholder (directly purchased):
This only applies to any direct purchase of shares. This does not include any shares included in mutual funds or other funds that are managed by a third party.
Stock Shareholder (ownership interest):
Should you indicate you are an owner of shares in an ineligible company, a representative from CME Outfitters or CE Concepts will follow up with you to discuss. Or, you can contact Susan Yarbrough at yarbroughs@cmeoutfitters.com directly.
Employment:
This only applies to employment or ownership as it relates to an ineligible company. Should you indicate you are an employee or owner of an ineligible company, a representative from CME Outfitters or CE Concepts will follow up with you to discuss. Or, you can contact Susan Yarbrough at yarbroughs@cmeoutfitters.com directly.
Other financial or material support:
Please describe financial relationships that may not fit neatly into any of the above categories.
Attestation*
I attest that the above information is correct as of date of submission.
Date of submission*
MM slash DD slash YYYY

Signature*
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Faculty Agreement and Disclosure 2023

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