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Conflict Of Disclosure Form

All Speakers Conflict of Interest COI Disclosure Form

COI form for CME&PD

This field is hidden when viewing the form

Conference Name

Title of CPD Activity(Required)

End Date of CPD Activity(Required)

DD dash MM dash YYYY

Start Date of CPD Activity(Required)

DD dash MM dash YYYY

What is your role in the CPD activity?(Required)

Speaker

Moderator

Member of the Scientific Planning Committee

Facilitator

Panelist

Author (of abstracts)

Other

Please select ALL that apply

Disclosure of Financial or In-kind Affiliations

Complete details of any financial or in-kind relationships you have or have had in the last 2 years with for-profit and not-for-profit organizations, including current employment.

Select one option(Required)

I do not have a relationship with a for-profit and/or a not-for-profit organization to disclose

I have a relationship with a for-profit and/or a not-for-profit organization to disclose

Speakers, moderators, facilitators, and/or authors who have nothing to declare should inform the audience that they cannot identify any conflict of interest.

Nature of relationship(s)

Please describe the nature of your relationship(s) by answering the questions below. You must disclose this information to your audience both verbally and in writing.

Do you have a relationship with any organization that involves direct financial payments including gifts, in-kind compensation or receipt of honoraria?(Required)

Yes

No

Disclosure of Relationship(s) with Organization(s)(Required)

Please use the + button to add additional organizations and include the description of the relationship in the corresponding field

Name of Organization

Description of relationship

Do you have a relationship with any organization that involves having membership on advisory board(s) or speakers’ bureau(s)?(Required)

Yes

No

Disclosure of Relationship(s) with Organization(s)(Required)

Please use the + button to add additional organizations and include the description of the relationship in the corresponding field

Name of Organization

Description of relationship

Do you have any funded grants or clinical trials?(Required)

Yes

No

Disclosure of Relationship(s) with Organization(s)

Please use the + button to add additional organizations and include the description of the relationship in the corresponding field

Name of Organization

Description of relationship

Do you have any patents on a drug, product or device; royalties?(Required)

Yes

No

Disclosure of Relationship(s) with Organization(s)(Required)

Please use the + button to add additional organizations and include the description of the relationship in the corresponding field

Name of Organization

Description of relationship

Do you have any other investments or relationships that could be seen by a reasonable, well-informed participant as having the potential to influence the content of the educational activity?(Required)

Yes

No

Disclosure of Relationship(s) with Organization(s)(Required)

Please use the + button to add additional organizations and include the description of the relationship in the corresponding field

Name of Organization

Description of relationship

To be completed by speakers, moderators, facilitators, panelists and authors only

I intend to make therapeutic recommendations for medications that have not received regulatory approval (i.e. “off-label” use of medication).(Required)

Yes

No

Note: You must declare all off-label use to the audience during your presentation.

Accreditation standards for CPD activities(Required)

I acknowledge that the National Standard requires that any description of therapeutic options utilize generic names (or both generic and trade names) and not reflect exclusivity and branding.

Yes

No

Acknowledgement

By clicking “I agree” you are acknowledging that the above information is accurate and that you understand that this information will be publicly available.(Required)

I agree

By clicking “I agree” you are acknowledging that the above information is accurate and that you understand that this information will be publicly available.

Name(Required)

First Last

Type of Health Professional(Required)

Select Specialty

Credentials - Physician(Required)

You can type and press enter if you don't find your specific credential in the list.

Credentials - Health Professionals(Required)

You can type and press enter if you don't find your specific credential in the list.

Institutions/Affiliations(Required)

Please list all your appointments/titles including University, Hospital, PCN. Use the + button to add more.

Cell Phone Number(Required)

We use this only for timely communication. Your contact information is never shared with anyone.

Email(Required)

Additional Emails

Signature(Required)

Date(Required)

MM slash DD slash YYYY

COI Forms are valid for 12 months. During this period the Office of CME&PD may use this form for other CME&PD activities that you agree to participate in.
If your COI form needs to be updated, please contact us.
Collection of personal information: Your personal information is collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of this information, please visit our Access to Information page.

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Personal Development

Examples of personal development include:

“Set personal goals with my leader when completing my annual review and teaching evaluations to improve my communication and teamwork”
“Set personal goals when debriefed following a 360 evaluation to improve my leadership ability”
“Reflect on and make changes to improve my work life balance after completion of a burn out assessment”
“Reflect and set SMART goals based on feedback from patient surveys to enhance my communication skills”

Quality improvement activity

Quality improvement activity examples:

CPSA Group Practice Review (GPR)
CPSA Patient Record Content Review – Physician Self-Review or Peer Review
CPSA Standard of Practice Review – Referral Consultation

Quality improvement methods

Quality improvement methods are processes used to assess data, identify gaps, develop an action plan for change and measure whether those changes produce the desired improvements. For example:

PDSA (Plan Do Study Act)
Lean
Six Sigma
Institute for Healthcare Improvement (IHI) Model for Improvement
Evidence-based Practice for Improving Quality (EPIQ)
Federation of Medical Regulatory Authorities of Canada (FMRAC) Physician Practice Improvement cycle
Alberta Health Services (AHS) Improvement Way

Data

Performance data
Screening data
Adherence to reporting standards
Feedback data from teaching
Patient outcomes data
Audit of processes of clinical care
Health Quality Council of Alberta (HQCA) data
Electronic Medical Record (EMR) data
MD Snapshot