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It explains why participants must be informed in advance about any affiliations or financial interests that could influence presentations by speakers, workshop leaders, or other resource persons. It defines “affiliation” and “financial interest,” provides a declaration section for the past two years, requests details when applicable, and includes spaces for name, educational activity, signature, date, plus organizer responsibilities for disclosure and transparency.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/potential-conflict-of-interests-disclosure-form/512714/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/potential-conflict-of-interests-disclosure-form/512714.png","ImageObject",300,407,{"name":92,"@type":93},"Mafia Boss","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-23","2026-10-06",true,{"@type":102,"interactionType":103,"userInteractionCount":24},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of this disclosure form in CME/CPD activities?","Question",{"text":112,"@type":113},"To inform the audience in advance of possible affiliations or financial interests that could influence the presentation, enabling participants to make an informed judgment.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What counts as an affiliation or a financial interest?",{"text":117,"@type":113},"Affiliation includes roles such as serving on an advisory board for a pharmaceutical company. Financial interest includes accepting invitations, remuneration, royalties, or research funds from a business corporation, or holding a financial interest.",{"name":119,"@type":110,"acceptedAnswer":120},"What should the organizer do regarding potential conflicts of interest?",{"text":121,"@type":113},"Ensure the form is completed by each resource person, make the information available in the course syllabus, and disclose the presence (or absence) of potential conflicts at the beginning of the presentation using oral and visual methods.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},512714,1791504042,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":24,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81,"preview_page_count":4},962090760730,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","# POTENTIAL CONFLICT OF INTERESTS DISCLOSURE FORM\n\nThe participants in a continuing medical education(CME)or continuing professional deveiopment(CPD)activity should know in advance of any affiliation or financial interest that could infiuence the presentation ofa speaker,a workshop leader or a resource person.The intention of disclosure is not to prevent a presenterwith a potentiai conflict of nterests from speaking,but to inform the audience in advance of the possibleaffiliations or financial interests.Since these facts are known openiy,the participants can render an informedjudgement on the content of the presentation itself.  \nAffiliation means,for example,acting as an advisory board member for a pharmaceutical company;financialinterest means,for example,accepting an invitation,gratuity or remuneration for services rendered,royalties or research funds from a business corporation,or holding a financial interest in an enterprise.  \n\n| Declaration of the resource person(speaker,facilitator,scientific committee member or others)   |  |  |  |\n| --- | --- | --- | --- |\n| 1 ruriently have,or !have had in the past two years,an affilation with/or financia nterest of any nature in a business  \u003Cbr>corporation,or I recerve remuneration,royaltes or research grants trom a busimess corporation  \u003Cbr>no☑ yes□   |  |  |  |\n| If yus,specfy the type of affitation(for example:I am an adviscr for the xY2 company,I have been invited recently bv  \u003Cbr>the XYZ company,i have been speaker for company XYZ,I an receving research funds from the ×YZ company,I am  \u003Cbr>holkdg shares in actions the XYZ company,etc.),the name(s)of the business corporation(s)(pharnaceutical or other)  \u003Cbr>and the period covered by the afiliation.   |  |  |  |\n| Type of affiliation   | Name of the corporation   |  | Period   |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n| NAME(block letters);  \u003Cbr>Aok/  \u003Cbr>KATSURA   |  |  |  |\n| Iutle and date or educational activity:  \u003Cbr>6~CTCcTosEe 2015  \u003Cbr>01s NeCN   |  |  |  |\n| Signature  \u003Cbr>kezt   |  | Date.  \u003Cbr>16,20/6,5  \u003Cbr>July  \u003Cbr>e.   |  |\n| Responsibility of the organizer   |  |  |  |\n\nIt is the responsiility of the organzer of an educational activity to nave this form completec by each resource person:speakers,tacilitators,scientfic committee members or others.The organizer shall ensure that the nformation is madeavaiabie to the participants by a notation in tne course syllabus and that potential conflicts of interests(or the absencethereof)are disclosed by the presenter at the beginning of his presentatron (oral and visual disclosure with slide).  \nFcr the sake of equity and transparency,the organzer will inform the participants that:  \n·  The resource person did nor declared any potential conflict of interests;  \n·  The resource person declared a potentiai conflict of nterests(in ths case,tne nature of the conflict will be describedas nentioned by the resource person);or  \n·  The resource person did not return che potential conflict of interests disciosure forn.","cbCaijHklYBDx1u3","https://ap.wps.com/l/cbCaijHklYBDx1u3","pdf",559332,"English","# Potential Conflict of Interests Disclosure Form\n## Purpose of Disclosure\n## Definitions: Affiliation and Financial Interest\n## Declaration of Resource Person\n## Organizer Responsibility and Transparency","[{\"question\":\"What is the purpose of this disclosure form in CME/CPD activities?\",\"answer\":\"To inform the audience in advance of possible affiliations or financial interests that could influence the presentation, enabling participants to make an informed judgment.\"},{\"question\":\"What counts as an affiliation or a financial interest?\",\"answer\":\"Affiliation includes roles such as serving on an advisory board for a pharmaceutical company. Financial interest includes accepting invitations, remuneration, royalties, or research funds from a business corporation, or holding a financial interest.\"},{\"question\":\"What should the organizer do regarding potential conflicts of interest?\",\"answer\":\"Ensure the form is completed by each resource person, make the information available in the course syllabus, and disclose the presence (or absence) of potential conflicts at the beginning of the presentation using oral and visual methods.\"}]","Potential Conflict of Interests Disclosure Form | PDF",1791274873]