Co-Presenter Bio and Disclosure Form

ACHA will generally*not accept, approve, or include in its annual meeting program any presentation in which the presenter(s) has a direct financial relationship with any for-profit business entity, and the presentation topic is directly related to the business entity, or its products and services. All disclosures that are determined by the ACHA Program Planning Committee Chair to be relevant relationships will be shared with the participants/learners in meeting materials and prior to the start of the educational activity.

* See ACHA General Policies for Presenters

ACHA 2017 Annual Meeting
Presenter, Speaker, Discussant, Respondent, Faculty COI/Disclosure Form.
Please read the ACHA General Policies for Presenters, the APHA Conflict of Interest Policy; the ANCC Continuing Education Content Integrity Standards, and the ACCME Commercial and Sponsorship Support Standards (links at bottom of form).
Session Title:
Name:
List your completed academic degree(s), institution where the degree was earned, and major or specialty area. (e.g., PhD, ABC University, clinical psychology) / Degree / Institution / Major or Specialty Area
List any current certifications
(e.g., CHES, APN, LPC)
Institution/Employer: / Address:
Job Title: / City/State/Zip:
Phone: / Email:
List your publications that are most relevant to the proposed topic (up to 10).
Biographical Qualification Statement: (Example: I have been the principal or co-principal of multiple federally funded grants focusing on the epidemiology of drug abuse, HIV prevention and co-occurring mental and drug use disorders. Among my scientific interests has been the development of strategies for preventing HIV and STDs in out-of-treatment drug users.)
I am qualified to give this specific presentation because…
Bio statement must state content expertise. Please submit your biographical qualification statement below. Also include any relevant academic appointments, involvement in professional organizations, and/or awards/honors received. Limit 75 words.
Conflict of Interest (COI) Disclosure - Resolution
A CE worthy educational activity/session must be developed and presented with independence, objectivity and scientific rigor, free from promotion of specific goods or services, or bias.
A Conflict of Interest (COI) is present if any relationship of a financial nature exists that would potentially bias the planner, program reviewer presenter, speaker, discussant, respondent, faculty because they may have an impact on the content of an educational activity.
Such a relationship may be:
  • with a commercial entity, or entity controlled/owned by an entity that produces, markets, re-sells, or distributes healthcare goods or services that are consumed by, or used on, patients/clients. Pharmaceutical or biomedical device entities whose goods or services are related to therapeutic areas are such commercial entities. Additional entities include those that develop, produce, market, or distribute products and services that promote wellness, and for-profit entities that provide administrative products and/or services used in student health.
  • A salary; consulting fee; honoraria; ownership interest except diversified mutual funds; private research or program contracts or grants; publications; royalties; membership on advisory or top level boards or panels that give remuneration.
Exempt entities that are not considered commercial entities for CE purposes are non-profits, governments, and non-healthcare related companies.
To award CE credits, a COI must be disclosed and resolved before presentation. Each presenter, speaker, discussant, respondent, faculty must agree not to promote the sale of goods or services, or insert bias when presenting the activity/session.

Required Disclosure: During the past 12 months have you, or your spouse or partner had a financial, professional or personal relationship (including self-employment and self-proprietorship) that might potentially bias and/or impact content of the educational activity/session:

___ Yes ___ No

If yes, list company (s) with relationship:

Relationship / Name of Commercial Company

Resolution: I agree not to promote any products, goods or services or to bias the educational, planning and selection of presenters and to protect the integrity of the content according to the ACHA General Policies for Presenters,APHA Conflict of Interest Policy,the ANCC Continuing Education Content Integrity Standards, and the ACCME Commercial and Sponsorship Support Standards.

Sign: / Date:

(Electronic/typed signatures are acceptable.)

FOR ACHA USE ONLY
Procedures used to resolve conflict of interest or potential bias, if applicable for this activity:
Not applicable since no conflict of interest.
Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the educational activity.
Not awarding contact hours for a portion or all of the educational activity.
Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the education activity to evaluate for commercial bias in the presentation.
Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.