MICHIGAN QUALITY IMPROVEMENT CONSORTIUM (MQIC) GUIDELINE
DEVELOPERS/CONTRIBUTORS DISCLOSURE DECLARATION
The MQIC Medical Directors’ Committee strives to insure balance, independence, objectivity,
and scientific rigor in its guideline development process. All guideline developers and
contributors, including the MQIC medical directors are expected to disclose any real or
apparent conflict(s) of interest that may have a direct bearing on the MQIC guideline
recommendations. This pertains to relationships with pharmaceutical companies, biomedical
device manufacturers, or other corporations whose products or services are related to the
guideline subject matter. The intent is not to prevent a contributor with a potential conflict of
interest from providing feedback. It is merely intended that any potential conflict should be
identified openly so that committee members form their own judgments about the feedback
with full disclosure of the facts. It remains for the committee to determine whether the
contributor's outside interests may reflect a possible bias in the guideline recommendations.
(please print or type)
I have no actual or potential conflict of interest in relation to this guideline.
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Date
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
guideline.
MQIC Guideline Topic(s): ___________________________________________________________
Affiliation/Financial Interest
Name of Organization(s)
Grant/Research Support
Consultant
Speakers' Bureau
Major Stock Shareholder
Other Financial or Material Support
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Your cooperation in complying with this standard is appreciated. Please return this form with your feedback on the
MQIC guidelines.