MLI Attestation for Potential Joint Providers, Educational Partners, and Collaborators

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Description an other

Medical Learning Institute Inc (MLI) is committed to ensuring that all continuing education (CE) activities are planned and implemented in accordance with Joint Accreditation for Interprofessional Continuing Education™ Criteria, Standards and Policies, the ACCME’s Standards for Integrity and Independence in Accredited Continuing Education and the European Board for Accreditation in Hematology.

Definitions:

Ineligible Company: An Ineligible Company is defined by the ACCME as any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by, or on, patients.

Joint Provider: A Joint Provider is an entity that has NOT received accreditation through a nationally recognized system such as ACCME, ANCC, ACPE, ASWB, Joint Accreditation for Interprofessional Continuing Education, etc., is not authorized to plan, present and award credit/contact hours for continuing education activities and is involved in contributing to the planning and/or content of the CE activity.

Educational Partner: An Educational Partner is an entity that HAS received accreditation through a nationally recognized system such as ACCME, ANCC, ACPE, ASWB, Joint Accreditation for Interprofessional Continuing Education, etc., is authorized to plan, present and award credit/contact hours for continuing education activities and is involved in contributing to the planning and/or content of the CE activity.

Collaborator: A Collaborator is not involved in contributing to the planning and/or content of the CE activity. Collaborators may include services providers, vendors, distribution channels, or other noneducational support.

MLI strives to provide clinically relevant educational activities for practitioners to promote improvements or quality in health care that are independent of the control of ineligible companies. As part of this commitment, MLI does not collaborate, partner with, or jointly provide CE activities with ineligible companies. To facilitate the determination of your eligibility to engage in a collaborative, educational partnership or joint providership relationship with MLI, please complete the following questionnaire and return it for review.

Anticipated Role with MLI *

Joint Provider
Educational Partner
Collaborator
Other (More Information Below)

Is your organization accredited to provide continuing education for health care professionals? *

My organization is not accredited
Joint Accreditation
ACCME
ANCC
ACPE
Other (More information below)

More Information:

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Name of Organization: *

Organization Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone Number:

Organization Website/URL:

Primary Contact: *

Primary Contact's Email *

Tell us about your organization *

(500 word max)

Attach Mission Statement

Click or drag files to this area to upload. You can upload up to 2 files.

Is your organization involved in providing commercial (promotion or marketing) or other company-directed activities or services for any ineligible companies? *

Yes
No
Unsure

This may include (but is not limited) to advertising, promotional services, publication planning, speaker bureau management, speaker training, and advisory board or consultant meeting support.

An Ineligible Company is defined by the ACCME as any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by, or on, patients.

Comments:

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Do you have a parent organization? *

Yes
No
Unsure

A Parent Organization is defined as an entity that owns and fiscally controls your organization (and any sister organizations, if applicable).

Parent Company: *

Parent Company Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent Organization's Website / URL: *

Description of Parent Company: *

Is your parent organization an ineligible company as defined by the ACCME? *

Yes
No
Unsure

An Ineligible Company is defined by the ACCME as any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on, patients.

Comments:

Do you have any 'sister' companies? (Is your organization part of a larger family of companies?) *

Yes
No
Unsure

Name(s) of Sister Companies *

Comment:

Are any of the sister companies considered an ineligible company? *

Yes
No
Unsure

An Ineligible Company is defined by the ACCME as any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on, patients.

Comments:

Are any sister companies providing commercial or other company-directed activities or services for any ineligible companies? *

Yes
No
Unsure

Comments:

Firewall Policy

If any affiliate (sister company) or subsidiary of your organization is involved in producing commercial or other company-directed activities for an ineligible company, there must be a formal firewall policy in place to that ensures the physical and functional separation between the organizations and individuals participating in accredited education. Organizations and individuals that are responsible for the content of independent medical education and those providing promotional or strategic services to ineligible companies must be independent, distinct, and insulated from one another. Sharing services related to faculty interaction and content development (e.g., medical writing, medical direction, substantive editing) among parent/sibling organizations is prohibited. Please verify that your organization has guidelines and firewalls in place to provide for separation of CE and promotional activity and staffing (e.g., independent, non-overlapping management, distinct and separate staff responsible for the development of educational content, separate physical locations, different telephone and fax numbers and Internet domains for e-mail addresses, individual computer networks, etc.)

File Upload - Firewall Policy

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Attach a copy of your corporate firewall policy.

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Name of Individual completing this form *

Title *

Signature *

Clear Signature

Email *

Date Completed *

Attestation: *

I hereby certify that the above information is correct. Medical Learning Institute Inc will be notified immediately if any of the information provided above changes.

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