UNC-Chapel Hill Digital and Lifelong Learning Accreditation Form

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PART 1:

Name and Credential

Email Address

Webinar Title

Webinar Description

Learning Objectives

Please create 3 or more learning objectives for your presentation. Objectives should begin with one of these verbs:

arrange, calculate, choose, compare, create, define, demonstrate, describe, differentiate, discuss, distinguish, explain, identify, implement, improve, label, list, locate, measure, modify, organize, perform, rate, recall, recognize, select, use

At the end of this lecture, the participant will be able to:

Learning Objective 1

Learning Objective 2

Learning Objective 3

Learning Objective 4

Learning Objective 5

Describe your education or experience (more than your title) to support participation in this planning or presenting:

Part II must by completed ONLY if a financial relationship with an ineligible company has been reported above.

Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?

YesNo

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Financial Relationship: Any relationship which benefits you financially.

Financial relationships include grants where the money goes to your organization, if you are the Principal Investigator. Financial relationships must be reported even if they have ended; in such cases, the end date should be noted in the Disclosure Grid.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME System are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Ex: pharmaceutical companies, device manufacturers.

Eligible organizations include hospitals, physician practices, diagnostic labs that do not sell proprietary products, education companies (such as Elsevier or UpToDate), insurance companies, software companies (including electronic medical record companies), and government agencies. If you are uncertain about the eligibility of an organization, list it on the Disclosure Grid.

Disclosure of Relevant Financial Relationships

Ownership Interest*

Individuals with a legal duty to act in the company’s best interests.

Excludes stockholders of publicly traded companies or holders of shares through a pension or mutual fund. Provide the name of the ineligible company and the relationship end date**.

Employee*

Individuals hired to work for another person or business for compensation and who are subject to the employer’s direction as to the details of how to perform the job.