{"id":1242,"date":"2020-10-16T15:22:32","date_gmt":"2020-10-16T19:22:32","guid":{"rendered":"https:\/\/achena.org\/?page_id=1242"},"modified":"2020-10-16T15:22:32","modified_gmt":"2020-10-16T19:22:32","slug":"cpd-financial-disclosure-appendix-c","status":"publish","type":"page","link":"https:\/\/achena.org\/refresh\/forms\/cpd-financial-disclosure-appendix-c\/","title":{"rendered":"CPD Financial Disclosure &#8211; Appendix C"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/refresh\/wp-json\/wp\/v2\/pages\/1242#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>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. <\/p><\/li><li id=\"field_3_29\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_29'>Course Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_29\" tabindex='49'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_29'>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 correct<\/div><\/li><li id=\"field_3_2\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_2'>Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_3_2' type='text' value='' class='medium'   tabindex='50'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'>Title of Presentation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_3_3' type='text' value='' class='medium'   tabindex='51'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What is your role in this CPD activity?<\/label><div class='gfield_description' id='gfield_description_3_5'>check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_5'><li class='gchoice gchoice_3_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Presenter'  id='choice_3_5_1' tabindex='52'  aria-describedby=\"gfield_description_3_5\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_5_1' id='label_3_5_1' class='gform-field-label gform-field-label--type-inline'>Presenter<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Provider\/Planner'  id='choice_3_5_2' tabindex='53'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_5_2' id='label_3_5_2' class='gform-field-label gform-field-label--type-inline'>Provider\/Planner<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_7\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='medium'   tabindex='54'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='medium'   tabindex='55'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_9\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_3_9' type='tel' value='' class='medium' tabindex='56'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_10' id='input_3_10' type='email' value='' class='medium' tabindex='57'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Is your presentation being sponsored by any company or commercial interest?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_11'><li class='gchoice gchoice_3_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Yes'  id='choice_3_11_1' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='No'  id='choice_3_11_2' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_2' id='label_3_11_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_14\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Disclosure<\/h2><\/li><li id=\"field_3_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you serve as a paid consultant, staff person, share-holder or do you receive grants, awards or compensation from a company that produces &lt;strong&gt;homeopathic products&lt;\/strong&gt; that will be discussed in your presentation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_13'>\n\t\t\t<li class='gchoice gchoice_3_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_3_13_0' tabindex='60'   \/>\n\t\t\t\t<label for='choice_3_13_0' id='label_3_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_3_13_1' tabindex='61'   \/>\n\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you serve as a paid consultant, staff person, share holder or do you receive grants, awards or compensation from a company that produces &lt;strong&gt;homeopathic software&lt;\/strong&gt; that will be discussed in your presentation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_15'>\n\t\t\t<li class='gchoice gchoice_3_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_3_15_0' tabindex='62'   \/>\n\t\t\t\t<label for='choice_3_15_0' id='label_3_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_3_15_1' tabindex='63'   \/>\n\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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 &lt;strong&gt;services&lt;\/strong&gt; that will be discussed in your presentation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_16'>\n\t\t\t<li class='gchoice gchoice_3_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_3_16_0' tabindex='64'   \/>\n\t\t\t\t<label for='choice_3_16_0' id='label_3_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_3_16_1' tabindex='65'   \/>\n\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_17\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>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.<\/strong><\/p><\/li><li id=\"field_3_18\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >List<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_18_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_18_col_2' class='gfield_list_col_even' \/><col id='gfield_list_18_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th scope=\"col\">Commercial Interest (Name of Company)<\/th><th scope=\"col\">Nature of Relevant Financial Relationship<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_18_cell1' data-label='Commercial Interest (Name of Company)'><input aria-invalid='false'   aria-label='Commercial Interest (Name of Company), Row 1' data-aria-label-template='Commercial Interest (Name of Company), Row {0}' type='text' name='input_18[]' value='' tabindex='66'  \/><\/td><td class='gfield_list_cell gfield_list_18_cell2' data-label='Nature of Relevant Financial Relationship'><input aria-invalid='false'   aria-label='Nature of Relevant Financial Relationship, Row 1' data-aria-label-template='Nature of Relevant Financial Relationship, Row {0}' type='text' name='input_18[]' value='' tabindex='67'  \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)'><img src='https:\/\/achena.org\/refresh\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\"><img src='https:\/\/achena.org\/refresh\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_3_26\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Resolution of Conflict of Interest<\/h2><\/li><li id=\"field_3_22\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Resolution of Conflict of Interest<\/label><div class='ginput_container ginput_container_consent'><input name='input_22.1' id='input_3_22_1' type='checkbox' value='1' tabindex='68' aria-describedby=\"gfield_consent_description_3_22\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_22_1' >I will support my presentation with the \u201cbest available evidence\u201d from the literature.<\/label><input type='hidden' name='input_22.2' value='I will support my presentation with the \u201cbest available evidence\u201d from the literature.' class='gform_hidden' \/><input type='hidden' name='input_22.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_22' tabindex='0'>I will support my presentation with the \u201cbest available evidence\u201d from the literature.<\/div><\/li><li id=\"field_3_23\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Resolution of Conflict of Interest<\/label><div class='ginput_container ginput_container_consent'><input name='input_23.1' id='input_3_23_1' type='checkbox' value='1' tabindex='69' aria-describedby=\"gfield_consent_description_3_23\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_23_1' >I will refrain from recommending or commenting on products\/ services for which I have a financial interest.<\/label><input type='hidden' name='input_23.2' value='I will refrain from recommending or commenting on products\/ services for which I have a financial interest.' class='gform_hidden' \/><input type='hidden' name='input_23.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_23' tabindex='0'>I will refrain from recommending or commenting on products\/ services for which I have a financial interest. <\/div><\/li><li id=\"field_3_24\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Resolution of Conflict of Interest<\/label><div class='ginput_container ginput_container_consent'><input name='input_24.1' id='input_3_24_1' type='checkbox' value='1' tabindex='70' aria-describedby=\"gfield_consent_description_3_24\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_24_1' >I will submit all slides and handouts in advance to allow for peer review.<\/label><input type='hidden' name='input_24.2' value='I will submit all slides and handouts in advance to allow for peer review.' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_24' tabindex='0'>I will submit all slides and handouts in advance to allow for peer review.<\/div><\/li><li id=\"field_3_25\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Resolution of Conflict of Interest<\/label><div class='ginput_container ginput_container_consent'><input name='input_25.1' id='input_3_25_1' type='checkbox' value='1' tabindex='71' aria-describedby=\"gfield_consent_description_3_25\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_25_1' >I will 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