All programming in which The Collaborative Education Institute (CEI) is in any way involved, whether as sole provider or cosponsor, shall exhibit fair content balance, providing the audience with information of multiple perspectives from which to develop an informed professional opinion. In addition, the fair balance will assure that information provided does not discuss any single commercial product. Faculty participating in any CEI educational offering will acknowledge and disclose any affiliation with organizations currently or in the past 12 months that could be a conflict of interest, and such information will be made available to the program participants.

1.	Program Name:*

2.	Presentation:*
	Title:   Date:   Time:

3.	Faculty Contact Email Address:*

4.	Faculty:*
	Name:   Credentials:   Title:   Business/Organization:

5.	I have no actual or potential conflict of interest in relation to this program.*
	-- Please Select --Yes No

6.	I have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
	Name of Organization(s): Receive grant/research support   Receive salary, royalty, or intellectual property rights   Consultant   Member of advisory committees or review panels, board membership   Speaker’s Bureau   Ownership Interest   (stocks, stock options and other ownership interest, excluding diversified mutual funds)   Receive other financial/material benefit

7.	I will be discusssing off-label use of medication(s) during my presentation.*
	-- Please Select --Yes No

8.	If yes, please elaborate.

9.	My spouse or partner has a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
	Name of Organization(s): Receive grant/research support   Receive salary, royalty, or intellectual property rights   Consultant   Member of advisory committees or review panels, board membership   Speaker’s Bureau   Ownership Interest   (stocks, stock options and other ownership interest, excluding diversified mutual funds)   Receive other financial/material benefit