CPD Financial Disclosure – Appendix C It is policy of ACHENA to ensure balance, independence, objectivity and full transparency in all CPD activities. All those involved in developing content or offering presentations must complete this form. Course Name* Note: This is used to pair this form submission to a master Course Approval Application submission, so please make sure the course name entered here is correctEvent* Title of Presentation* What is your role in this CPD activity?check all that apply Presenter Provider/Planner Name* Title Phone*Email* Is your presentation being sponsored by any company or commercial interest?* Yes No DisclosureDo you serve as a paid consultant, staff person, share-holder or do you receive grants, awards or compensation from a company that produces <strong>homeopathic products</strong> that will be discussed in your presentation?* Yes No Do you serve as a paid consultant, staff person, share holder or do you receive grants, awards or compensation from a company that produces <strong>homeopathic software</strong> that will be discussed in your presentation?* Yes No Do you serve as a paid consultant, staff person, share-holder or do you receive grants, awards or compensation from a company with a financial interest in any <strong>services</strong> that will be discussed in your presentation?* Yes No If NO, skip to DECLARATION section below. If YES, please check the boxes below that indicate how you will ensure full transparency of your financial interests and benefits.ListCommercial Interest (Name of Company)Nature of Relevant Financial Relationship Resolution of Conflict of InterestResolution of Conflict of Interest I will support my presentation with the “best available evidence” from the literature.I will support my presentation with the “best available evidence” from the literature.Resolution of Conflict of Interest I will refrain from recommending or commenting on products/ services for which I have a financial interest.I will refrain from recommending or commenting on products/ services for which I have a financial interest. Resolution of Conflict of Interest I will submit all slides and handouts in advance to allow for peer review.I will submit all slides and handouts in advance to allow for peer review.Resolution of Conflict of Interest I will or have divested myself of this financial relationship.I will or have divested myself of this financial relationship.Declaration By typing your name below and submitting this form, you agree to the following: You will uphold academic standards to ensure balance, independence, and full transparency in my role in the development or presentation of this CPD activity. You agree to disclose all financial relationships and also agree to disclose if you do not have any financial relationships.Signature*
