For more information, contact:

Jessica C. Wells, MS -
Vice President, Medical Education
Phone: 615-222-6995
Fax: 615-222-6464
Email: jessica.wells@baptisthospital.com

Beverly Upchurch - CME Coordinator
Phone: 615-222-4065
Fax: 615-222-6464
Email: bupch@stthomas.org

Tristin Casteel - CME Coordinator
Phone: 615-222-4059
Fax: 615-222-6464
Email: tristin.casteel@stthomas.org

Lauren Johnson - CME Coordinator
Phone: 615-222-4127
Fax: 615-222-6464
E-mail: lauren.johnson@stthomas.org

Alexis Tait - Office Supervisor
Phone: 615-222-2007
Fax: 615-222-6464
E-mail: alexis.tait@stthomas.org

Name of CME Activity:
Date of Activity:
Name of Discloser:
I am a/an:
  • instructor
  • planner
  • manager
As a faculty member of Saint Thomas Health Services, please indicate your acceptance of the following standards of independence by checking the box next to each.
Best Available Evidence
Recommendations involving clinical medicine in this activity will be based on the best available evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.
Sources and Limitations of Data
To the extent practical, recommendations involving clinical medicine in this activity will be substantiated by peer-reviewed sources. Presenters will make meaningful disclosure to the attendees if products or procedures discussed are off-label, unlabeled, experimental, and/or investigational (not FDA approved), and any limitations on the information that is presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
Scientific Integrity
All scientific research referred to, reported or used in support or justification of a patient care recommendation will conform to generally accepted standards of experimental design, data collection and analysis.
Free of Commercial Bias
Activity content presented to learners will be free of commercial bias. No product, service, or therapeutic option will be over-represented when comparing competing products, services, and therapeutic options. When appropriate, generic names or trade names from several companies will be used.
Serve the Public Interest
Any selection of topics, instructional content and personnel I make for this activity will be done to serve the public interest by improving the quality of healthcare. To the best of my ability, I will not let any personal financial relationships influence this selection process.
Disclosure to Provider
All persons who have control or influence of activity content (planning committee members, speakers, authors, etc) will disclose relevant financial relationships (stock ownership, consulting fees etc) using the Conflict of Interest (COI) disclosure form.
Content Validation
In accordance with ACCME rules, content must be reviewed to ensure fair balance and objectivity exist with presentations. I understand that once I have reviewed the speaker presentations and identified and resolved any conflicts of interest, I will complete and sign a Validation of Content Form for inclusion in the activity file.
Disclosure to Learners
All persons with control of activity content will disclosure their relevant financial relationships and full disclosure will be made to learners prior to the start of the educational content. Disclosures will be done in print and via projected materials or verbally.
Signature of Reporting Individual
Date of Submission
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