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H Letter of Agreement Regarding Terms, Conditions and Purposes of Support for a Scientific/Educational Activity between Midwestern University Chicago College of Osteopathic Medicine and ___________________________ (Company) Title of CME Activity __________________________________________ Location ____________________________________ Date/s _______________________________ Commercial Supporter (Company Name/Branch): ____________________________________________ Address: _____________________________________________________________________________ City, State, Zip: _______________________________________________________________________ Contact(s): ___________________________________________________________________________ Telephone: _________________________________ Fax: ___________________________________ The above company wishes to provide support for the named continuing medical education activity by means of (indicate which option): 1. Unrestricted education grant (for support of the CME activity) in the amount of $____________. 2. Restricted grant to reimburse expenses for: A. Speaker/s 1/_______________________________________________________________ 2/_______________________________________________________________ To include all Expenses__________ Travel Only___________ Honorarium Only________ (Honorarium Amount to be determined by Course Director) B. Support for catering functions (specify)___________________________________________ In the amount of $_________________________ (See 10.d. on the back of this agreement) C. Other (e.g. equipment loan, brochure distribution, etc.)_______________________________ ___________________________________________________________________________ Conditions Statement of Purpose: Program is for scientific and educational purposes only and will not promote the companys products, directly or indirectly. Control of Content & Selection of Presenters & Moderators: Accredited Sponsor is ultimately responsible for control of content and selection of presenters and moderators. Company, or its agents, will respond only to provider-initiated requests for suggestions of presenter or sources of possible presenters. Company will suggest more than one name (if possible): will provide speaker qualifications; will disclose financial or other relationships between company and speaker, and will provide this information in writing. Accredited Sponsor will record role of Company, or its agents, in suggesting presenter(s); will seek suggestions from other sources, and will make selection of presenter(s) based on balance and independence. Conditions Disclosure of Financial Relationships: Accredited Sponsor will ensure disclosure to the audience of (a) Company funding and (b) any significant relationship between the Accredited Sponsor and the company (e.g., grant recipient) or between individual speakers or moderators and the Company. Involvement in Content: There will be no scripting, emphasis or influence on content by Company or its agents. Ancillary Promotional Activities: No promotional activities will be permitted in the same room or obligate path as the educational activity. No product advertisements will be permitted in the program room. Objectivity & Balance: Accredited Sponsor will make every effort to ensure that data regarding the Companys products (or competing products) are objectively selected and presented, with favorable and unfavorable information and balanced discussion of prevailing information on the product(s) and/or alternative treatments. Limitations of Data: Accredited Sponsor will ensure, to the extent possible,, disclosure of limitations of data, e.g., ongoing research, interim analyses, preliminary data, or unsupported opinion. Discussion of Unapproved Uses: Accredited Sponsor will require that the presenters disclose when a product is not approved in the United States for the use under discussion. Opportunities for Debate: Accredited Sponsor will ensure opportunities for questioning or scientific debate. Independence of Accredited Sponsor in the Use of Contributed Funds: Funds should be in the form of an unrestricted educational grant made payable to Midwestern University (accredited sponsor). All other support associated with this CME activity (e.g., distributing brochures, preparing slides) must be given with full knowledge and approval of Midwestern University (accredited sponsor). No other funds from the Company will be paid to the program director, faculty, or others involved with the CME activity (additional honoraria, extra social events, etc.). Funds may be used to cover the cost of one or more modest social activities held in conjunction with the educational program which furthers the CME educational experience and/or allows an educational discussion and exchange of ideas. If Company sponsors a social event, the requirements set forth in Sections 1, 3-5 will still apply. The Company agrees to abide by all requirements of the ACCME Standards for Commercial Support of Continuing Medical Education and AOA Guidelines for Relationships between Accredited Sponsors and Company of CME. Accredited Provider agrees to: 1) abide by the ACCME Standards for Commercial Support of Continuing Medical Education and Guidelines for Relationships between Accredited Sponsors and Company of CME; 2) acknowledge educational support form the Company in program brochures, syllabi, and other program materials; and 3) upon request, furnish the Company a report concerning the expenditure of the funds provided. Agreed Company Representative (name): _______________________________________________ Signature: ______________________________________ Date: ______________________ Course Director (name):________________________________________________________ Signature: ______________________________________ Date: ______________________ CME Department Director or Designee: (name):_________________________________________ Signature: ______________________________________ Date: ______________________   c. / 9 : D E . / _ ` GH|}kl `aTU hYNCJ h-CJ h-CJ h->*CJh-5CJ\; . / 9 : D E . / _ ` P^P`$a$ T GH |}2Yh^h & F^YDkl `aSU$a$ & F(1h/ =!"#$%@@@ NormalCJ_HaJmH sH tH >@> Heading 1$$@&a$>*DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List 0>@0 Title$a$>* * ./9:DE./_`TGH | }  2YDkl `aSU00000000000000000000000000000000000000000 0 000 0}  0}  0}  0}  0}  0}  0}  0 }  0}  0}  0}  0} 000000000000000000 ./9:DE./_`TGH | }  2YDkl `aSUM90M90O90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90O90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90M90L Y}}}}d}|}$}k}Tn}/}}}l}}"}]} {{mmx     !!w   B *urn:schemas-microsoft-com:office:smarttagscountry-region= *urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName8*urn:schemas-microsoft-com:office:smarttagsCityV*urn:schemas-microsoft-com:office:smarttagsplacehttp://www.5iantlavalamp.com/      /:!*~333333 ^_FG{ fgMidwestern UniversityMidwestern UniversityMidwestern UniversityMidwestern UniversityMidwestern UniversityMidwestern UniversityMidwestern UniversityMidwestern UniversityBDohmaAPatto 'X^`o(.^`o(.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. '        -YN|E@] @Unknowng: Times New RomanTimes New Roman5SymbolG& : Arialhelvetica"h 3rYaYa$24d3QH(?YNLetter of AgreementjjacobAPatto Oh+'0  8 D P \hpxLetter of AgreementettjjacobojacjacNormaloAPattoo2atMicrosoft Word 10.0@F#@֜ @@S6@@S6Y՜.+,D՜.+,T hp  Midwestern UniversitySa{ Letter of Agreement Title@@4_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnceGUpdates for CME WebsiteBDohma@midwestern.edueDohman, Brendarohm  !"#$%&()*+,-.01234569Root Entry F^6;1Table!WordDocument**SummaryInformation('DocumentSummaryInformation8/CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q