Free Microsoft Word - QME Form 119 clean - California

Administrative Director, Division of Workers' Compensation ATTN.: Medical Unit P. O. Box 71010 Oakland, CA 94612

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FACULTY DISCLOSURE OF COMMERCIAL INTEREST

As an education provider accredited by the Administrative Director, (Education Provider's Name) must ensure objectivity in its educational activities. Having an interest or ownership in a business does not prevent a physician from making a presentation, but the relationship must be disclosed to the audience, in accordance with Administrative Director's regulations. Please complete the information below.

TITLE OF COURSE: DATE: NAME OF FACULTY: TITLE OF PRESENTATION: (Check one) [ ] Neither I, nor my family members, have any past or present financial arrangements or affiliations with any business involved in the products/services which will be discussed at this symposium. (Skip to signature.) [ ] I, or one or more of my family members, have a financial interest/arrangement or affiliation with the following businesses which offer products/services that I will discuss at this symposium. Name(s) of Business(es)

Affiliation/Financial Interest Grants/Research Support Consultant Speaker's Bureau Major Stock Shareholder Other Financial or Material Interest

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Date

QME Form 119 (rev. February 2009)