CME Disclosure Form (Template 4-26) - CME Application General Use

University of Nevada, Reno School of Medicine
Disclosure Form

As a prospective planner or presenter, we would like to ask for your help in protecting our learning environment from industry influence. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at cme@med.unr.edu.

First Name

Last Name

Degree or Credentials

Organization Name

Email Address

2. What is your prospective role in the educational activity? (choose all that apply)

Presenter
Planner
Author, Writer
Reviewer
Other - Write In Please enter an 'other' value for this selection.

3. Title of Educational Activity

4. Date of Educational Activity