NMNA Accredited Approver Unit

Planning Committee/ Presenter/Author Biographical and Conflict of Interest Form Revised 09/01/2015

Title of Educational Activity:

Education Activity Date:

Role in Educational Activity: (Check all that apply)

Planning Committee Member (not nurse planner) Presenter/Author

Other – Describe:

Section 1: Demographic Data

Name with Credentials/Degrees: __

If RN, Nursing Degree(s)(all that apply):Diploma AD BSNMastersDoctorate

Phone Number: __ Email Address: _

Current Employer and Position/Title: _

Section 2: Expertise - Planning Committee

If a planning committee member, select area of expertise specific to the educational activity listed above:

Content Expert Administrative personOther (explain):

Please describe expertise and years of training specific to your role in this educational activity. (If the description of expertise does not provide adequate information, the Accredited Approver may request additional documentation.)

Section 3: Expertise - Presenter/Faculty/Author

An "X" in this box identifies the expertise information is the same as listed above ONLY if both Planner & Presenter.

Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the Accredited Approver may request additional documentation.)

Section 4: Conflict of Interest

Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner? Yes No

If yes, complete the table below for all actual, potential or perceived conflicts of interest**:

Check all that apply / Category / Description
Salary
Royalty
Stock
Speakers Bureau
Consultant
Other

** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.

Section 5: Conflict Resolution (to be completed by Nurse Planner)

Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply)

Not applicable since no conflict of interest

Removed individual, with conflict of interest, from participating in all parts of the educational activity.

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 educational 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.

Other - Describe:

Section 6: Confirmation/approval of veracity of biographical/COI information.

Note to Nurse Planner: if you or administrative person is transferring information on speakers from resumes or C.V.s, the presenter/author must have an opportunity to review what was typed onto the form for accuracy, and have verified this with you before the document is “signed.”

I confirm I was provided the Definition of Financial/Conflict of Interest when completing my Bio/COI form.

I confirm that the information reported above is accurate. I understand that this information will be disclosed publicly in conference materials or publications, where appropriate. I further understand that the program provider reserves the right to replace me in an educational program, decline to publish my work, or otherwise limit my participation in this particular activity if they believe that significant conflict of interest exists. I agree to notify the program provider if there is any change in the information that I have provided regarding my financial relationships prior to the educational program or publication of my work.

Please type your name and credentials in the electronic signature box if submitting electronically. This will act as your electronic signature for this form.

E-signature

DateName, credentials

______

Nurse Planner Signature:

An X in the box below serves as the electronic signature of the Nurse Planner reviewing this Bio/COI form for content and conflict resolutions required on this Bio/COI form.

Electronic signature

Date completedName, Credentials