Financial & Non-Financial Disclosure Statement

Name *

First Name

Last Name

I am serving as...

Course Planner

Instructional Personnel (i.e., Presenter/Author/Content Creator)

Disclosures

Disclosures All planners and presenters must disclose relevant financial and nonfinancial relationships, or lack thereof, to the Provider during course planning and to learners at the start of the course. Presenters need only disclose those relationships that are relevant to and may influence course content and delivery.  Financial Relationships Financial relationships may include receiving a salary, royalty, intellectual property rights, gifts, speaking fee, consulting fee, honorarium, ownership interest, or other financial benefit. Financial relationships can also include “contracted research” in which the institution receives the grant, manages the funds, and the individual is the principal or named investigator on the grant. Do you have financial relationships that are relevant to the proposed course's content to disclose?

Yes

No

Attestation

I attest that the information in this disclosure is accurate at the time of completion, and I agree to notify Holistic Circus Therapy of any changes to this information between now and the presentation.

Review of Information Disclosed by Course Planners and Instructional Personnel

Step 1. Provider’s representative reviews the disclosure form, the learner outcomes, the individual’s biography or resume and all other course related materials. Step 2. Provider’s representative identifies any questions about the disclosure information. Step 3. Provider’s representative contacts the planner or instructional personnel to discuss the disclosure information provided. Step 4. Provider’s representative determines if the individual (check one):

has financial and/or nonfinancial relationships relevant to the course content and a resolution process is required. (Go to “Resolution of Disclosed Relevant Relationships.”)

has no relevant financial or nonfinancial relationships to the course content and no resolution process is required. (For instructional personnel, go to “Disclosure to Learners.” For course planners, stop.)

has disclosed relationships deemed not relevant to the course content and no resolution process is required. (For instructional personnel, go to “Disclosure to Learners.” For course planners, stop.)

Resolution of Disclosed Relevant Relationships

Check the methods used to resolve the identified relevant relationship(s) and enhance transparency.

Determined that disclosing the relevant relationship(s) to learners was sufficient to minimize potential conflict of interest.

Used a peer review process (process by which materials are reviewed by experts in that topic area to ensure the data support the conclusions before they are accepted for presentation or publication). If necessary, instructional personnel will be required to revise content based on recommendations from the peer review.

Changed the focus of the content so that is does not relate to the relevant relationship

Changed the content/topic of the individual’s educational assignment so that it does not relate to the relevant relationship

Limited the individual’s content to a report without practice recommendations (if individual was funded by a commercial company to perform research, the individual’s presentation may be limited to research data and results)

Limited the role of the individual to reporting practice recommendations based on formal structured review of the literature with the inclusion and exclusion criteria stated (evidencebased)

The individual documented the ‘best available evidence’ to support their recommendations. (e.g., individual provided adequate references)

Chose not to select the individual as a planner and/or instructional personnel

Disclosure to Learners

Step 1. Develop the instructional personnel disclosure statement with information from the disclosure form and discussions with the instructional personnel: Select the applicable format:

Option 1: [Insert instructional personnel name] has no relevant financial or nonfinancial relationships to disclose.

Option 2: [Insert instructional personnel name] has the following relevant financial relationships to disclose: [insert name of organization and type of financial relationship] and relevant nonfinancial relationships to disclose: [insert name of organization and type of nonfinancial relationship].

Option 3: [Insert instructional personnel name] has the following relevant financial relationship to disclose: [insert name of organization and type of financial relationship] and no relevant nonfinancial relationships to disclose.

Option 4: [Insert instructional personnel name] has no relevant financial relationships to disclose and the following relevant nonfinancial relationship to disclose [insert name of organization and type of nonfinancial relationship].

Step 2. Send the draft instructional personnel disclosure statement to the instructional personnel for review and approval. Step 3. Finalize and provide instructional personnel disclosure statement to potential registrants prior to the start of the course. Indicate where the statement will be published (check all that apply):

Printed brochure

Website

Email blasts

Other

Step 4. Ensure that the agreed upon instructional personnel disclosure statement will be announced (verbally and/or in writing) at the start of the course. Step 5. Contact instructional personnel on or before [insert date] to identify any relevant financial and nonfinancial relationships that have developed after course planning and prior to course delivery. Complete the following after contacting the instructional personnel.

Instructional personnel disclosure statement unchanged

Changes in relevant relationships