Select all that apply:

Planning Committee Member

Faculty/Presenters/Author

Content Reviewer

Other-Describe:

Biographical Data and Conflict of Interest Form

To complete the form, highlight the shaded areas and begin typing. The shaded area will expand to
allocate space for text. (Hit the Enter button to start a new line.) Once form is complete, please submit to Margie Cox ()

Title of Educational Activity:

Educational Activity Date:

Name:

(Name, Degrees and Credentials)

Home Address OR Business Address:

Day Telephone: ()-Ext.E-Mail Address:

Present Position (Title) and Employer:

Education:

Degree / Institution
(Name, City, State) / Major Area of Study

PlannersIf you are a planning committee member, select area of expertise specific to the educational activity.
Nurse Planner (knowledge of the CNE process)

Content Expert

Planning Committee Member

Other

Describe your expertise and years of training specific to the educational activity listed above:

Faculty/Presenters

Check here if you are a member of the Planning Committee and your information is the same as above.

Describe your expertise and years of training specific to the educational activity listed above:

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner or faculty and/or his/her immediate family members have any relationships with sources of commercial support, e.g. pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas.

ANCC considers relationships occurring within the 12 months prior to the implementation date of the activity as relevant to conflict of interest. When a person divests himself/herself of a relationship, it ceases to be a conflict of interest but must be disclosed to the learners for 12 months after the termination of the relationship.

All planners and faculty participating in CNE activities must disclose to the audience any:

  • Relationship with companies who manufacture products used in the treatment of the subjects under discussion;
  • Relationship between the planner and faculty and commercial supporters(s) of the activity.

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

Is there a relationship with companies that manufacture products used in the treatment of the subjects under discussion by you or your spouse/partner?

Yes No

If Yes, list company(ies) with relationship:

Relationship

Research Support

Speaker’s Bureau

Consultant

Shareholder

Other Support

Large Gift(s)

Conflict Resolution(to be completed by Nurse Planner)

All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity. How will any conflict of interest be resolved?

N/A; No conflict of interest exist

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 longerrelevant 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:

Statement of Understanding

An ‘X’ in the box below serves as the electronic signature of the individual completing this Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

Electronic Signature (required)Date:

Completed by Name and Credentials

______

Nurse Planner: An ‘x’ in the box below serves as the electronic signature of the Nurse Planner/Planning Committee member reviewing the content of this Biographical/Conflict of Interest Form.If this form is for the Nurse Planner, another member of the Planning Committee must review and sign.

Nurse Planner

Planning Committee member

Electronic Signature (required)Date:

Completed by Name and Credentials

2013 ANCC StandardsNemours/Alfred I. duPont Hospital for ChildrenPage 1 of 3