Technical Expert Panel Nomination Disclosure Agreement Form printable pdf download

Technical Expert Panel

Technical Expert Panel (TEP) Nomination/ Disclosure/Agreement Form

Project Name: Development of Measures of High-Acuity Care Visits after Outpatient Endoscopy or Colonoscopy

Procedures

Instructions

Technical expert panel (TEP) applicants/nominees must submit the following documents along with this completed and

signed form in order to be considered for inclusion on the TEP:

A statement of interest summarizing relevant expertise and knowledge of the applicant (2-page maximum).

A curriculum vitae (CV) and/or list of relevant experience (e.g., publications) (10-page maximum).

A disclosure of any current and past activities that may indicate a conflict of interest. As a contractor for CMS, Yale

New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE), must ensure

balance, independence, objectivity and scientific rigor in its measure development activities.

Send completed and signed form, statement of interest, and CV to CORE with “Nomination” in the subject line at

ambulatoryprocedures@yale.edu. Due by 5pm ET, June 9, 2013.

All potential TEP members must disclose to CORE, CMS, and other TEP members any significant financial interest or other

relationships that may affect their judgment or perceptions. The intent of this disclosure is not to prevent individuals with

potential for conflict of interest from serving on the TEP, but to provide CORE, CMS, and other TEP members the

information to form their own judgments. It is for the measure contractor, CMS, and other TEP members to decide if the

individual’s interest or relationships may affect the discussions or conclusions. Conflict of interest glossary of terms can be

found at https://

Applicant/nominee information (self-nominations are acceptable)

First and last name:

Suffix/degrees (RN, MD, PhD, etc.)/title:

Organization:

Mailing address:

Telephone/fax number(s):

Email address:

Person recommending the nominee

Complete this section only if you are nominating a third party for the TEP. You must sign this form and attest that you have

notified the nominee of this action and that they are agreeable to serving on the TEP. The measure contractor will request

the required information from the nominee.

First and last name:

Suffix (RN, MD, PhD, etc.)/title:

Organization:

Mailing address:

Telephone/fax number(s):

Email address:

I attest that I have notified the nominee of this action and that he/she is agreeable to serving on the TEP.

Signature: ______________________________________________

Date: _________________

A Blueprint for the CMS Measures Management System, Version 9

Health Services Advisory Group, Inc.

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Technical Expert Panel Nomination Disclosure Agreement Form