CAFP Disclosure of Interest Form

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The CAFP, as an ACCME-accredited provider, is required by the New Standards of Commercial Support, to identify, manage or resolve any conflict of interest for any individual who may have influence over educational content provided by the CAFP. Our policy requires us to collect disclosure forms from any individual who may have an influence on any educational content. Please complete the disclosure form below, and return it to Shelly Rodrigues. It will be held in confidence in our files.

First: List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies, with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant relationships of your spouse or partner that you are aware of to be yours. Use another page if necessary.

Second: Describe what you or your spouse/partner received (salary, honorarium etc). The CAFP does NOT want to know how much you received.

Third: Describe your role.

1. Please fill out the form below and we will be in touch shortly.

Full Name *This question is required

Degree *This question is required

Organization

Street Address *This question is required

City *This question is required

State *This question is required

Postal Code *This question is required

Email Address *This question is required

Phone Number *This question is required

2. Please check all appropriate CAFP activities. *This question is required

3. Describe the commercial interest and the nature of the relationship.

3. Describe the commercial interest and the nature of the relationship.	What was received?	For what role?	From whom (commercial interest)?
Grant/Research support
Consultant
Speakers' Bureau
Shareholder
Board/Committee member
Other:

4. Please select from the drop down below if you have NO relevant relationships to disclose.

5. Date: *This question is required

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Thank you for completing the CAFP's Disclosure of Relevant Financial or Other Relationships form. This disclosure is valid for one year, but should you have relevant changes within the year, please notify CAFP staff. You will be contacted by a CAFP staff member if there are questions pertaining to your disclosure.

Questions? Contact Shelly Rodrigues, CAFP Deputy EVP, 415-345-8667 or srodrigues@familydocs.org