The Dental Forum of Milwaukee



Regarding Terms, Conditions and Purposes of an Educational Grant

between The Dental Forum of Milwaukee  and:

(Form must be typed or printed legibly)

Commercial Supporter (Company Name/Branch)____________________________________

Title of Activity_______________________________________________________________

Location         ._________________________________ Date(s)________________________

Address                ______________________________________________________________________

City.State, Zip_   ______________________________________________________________________

Telephone______________Fax_________________ Contact Person______________________



The above company wishes to provide support for the named continuing education activity by means of an unrestricted educational grant for support of this activity in the amount of $ _______________.


1.    Statement of Purpose: program is for scientific and educational purposes only and will not directly promote the company's products.

2.   Control of Content & Selection of Presenters & Moderators:  The Dental Forum of Milwaukee is responsible for control of content and selection of presenters and moderators. The Company agrees not to direct the content of the program. The Company, or its agents, will respond only to The Dental Forum initiated requests for suggestions of presenters or sources of possible presenters. The Company will suggest more than one name (if possible); will provide speaker qualifications; will disclose financial or other relationships between Company and speaker. The Dental Forum will record role of Company, or its agents, in suggesting presenters; will seek suggestions from other sources, and will make selection of presenters based on balance and independence.

3.   Disclosure of Financial Relationships: The Dental Forum will ensure meaningful disclosure to the audience at the time of the program, of (a) Company funding and (b) any significant relationship between The Dental Forum and the Company (e.g., grant recipient) or between individual speakers or moderators and the Company.

4.   Involvement in Content: there will be no "scripting", emphasis, or direction of content by the Company or its agents.

5.   Objectivity & Balance: The Dental Forum will make every effort to ensure that data regarding the company's products (or competing products) are objectively selected and presented, with favorable and unfavorable information and balanced discussion of prevailing information in the product(s) and/or alternative treatments.

6.   Limitations on Data: The Dental Forum will ensure, to the extent possible, meaningful disclosure of limitations on data, e-g., ongoing research, interim analyses, preliminary data, or unsupported opinion.

7.   Discussion of Unapproved Uses: The Dental Forum will require that presenters disclose when a product is not approved in the United States for the use under discussion.

8.   Opportunities for Debate: The Dental Forum will ensure meaningful opportunities for questioning or scientific debate.

The Commercial Supporter agrees to abide by all the requirements of the Standards for Commercial Support of Continuing Education for Health Professionals.

The Dental Forum agrees to: 1) abide by the Standards for Commercial Support of Continuing Education for Health Professionals, 2) acknowledge educational support from the commercial company in program announcements and presenter introductions, and 3) upon request, furnish the commercial supporter a report concerning the expenditure of the funds provided.



AGREED Commercial Company Representative: (name)

















The Dental Forum of Milwaukee Program Chair Signature