ࡱ>  bjbj ffz-r r BB4h.l3"NJL^^^1111111,5T8^)2^<"^^^)2 BB:3 ^jB81 ^1 [-z.LJ.1P3031.8 8$. . /^^^)2)2 ^^^38^^^^^^^^^r :   pro Continuing Education CNE/CME Biographical Data and Conflict of Interest Form Title of Educational Activity: Education Activity Date: ___________________________________ Role in Educational Activity: (Check all that apply)  FORMTEXT       Nurse Planner  FORMTEXT       Planning Committee Member  FORMTEXT       Faculty/Presenter/Author My ro Role on the planning committee is: (Check all that apply)  FORMTEXT       Content Expert  FORMTEXT        FORMTEXT       Target Audience  FORMTEXT       Adherence to ANCC COA/MONA Educational Design Criteria Section 1: Demographic Data/Brief Bio Name with Credentials/Degrees: If RN, Nursing Degree(s):  FORMTEXT       AD  FORMTEXT       Diploma  FORMTEXT       BSN  FORMTEXT       Masters  FORMTEXT       Doctorate Address: ___________________________________________________________________________ Phone Number: ______________________________ Email Address: ________________________ Current Employer and Position/Title: _____________________________________________________ Education: (include basic preparation through highest degree held) Degree Institution (Name, City, State) Major area of study Year Degree Awarded ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Section 2: Expertise - Planning Committee If you are a planning committee member, select area of expertise specific to the educational activity listed above:  FORMTEXT       Knowledge about the Nursing CE Process  FORMTEXT       Other  FORMTEXT       Content Expert Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, additional documentation may be requested.) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMTEXT      An "X" on this line indicates that a CV is on file with SLU SON Department of Continuing Nursing Education Section 3: Expertise - Presenters/Faculty/Authors  FORMTEXT      An "X" on this line identifies the expertise information is the same as listed above. Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, additional documentation may be requested.) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMTEXT      An "X" on this line indicates that a CV is on file with SLU SON Department of Continuing Nursing Education Section 4: Actual, Potential & Perceived Conflict of Interest The potential for Conflict of Interest (COI) exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest, the products or services of which are pertinent to the content of the educational activity. Actions must be taken to resolve any potential or actual COI for planners, presenters/faculty/authors or content reviewers prior to the start of the educational activity. Each individual who is in a position to control or influence the content of an education activity must disclose all relevant relationships with any commercial interest, including but not limited to members of the planning committee, speakers, presenters, faculty, authors, and/or content reviewers. Relevant Relationships, as defined by ANCC, are relationships that are expected to result in financial benefit from a commercial interest organization, the products or services of which are related to the content of the educational activity. Relationships with any commercial interest of the individuals spouse/partner may be relevant relationships and must be reported, evaluated and resolved. Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options), grants, contracts, or other financial benefit directly or indirectly from the commercial interest. Financial benefits may be associated with employment, management positions, stockholder, independent contractor relationships (including contracted research), other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected. Relevant relationships can also include contracted research where the institution receives a grant and manages the grant funds and the individual is the principal or a named investigator on the grant. Commercial Interest, as defined by ANCC, is any entity producing, marketing, re-selling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes healthcare goods or services consumed by, or used on, patients. Nonprofit or government organizations, non-healthcare-related companies, healthcare facilities, and group medical practices are not considered commercial interests. Individuals found to have a COI are not eligible to serve as a/the Nurse Planner, but may be able to serve on the planning committee or as a presenter/author if measures are taken to resolve the COI. Employees or representatives of a commercial interest may not serve as a Planner of an educational activity, although they may be eligible to serve as faculty if measures are taken to resolve any potential conflict of interest. Over the past 12 months, have you or your spouse/partner had a financial relationship with a commercial interest whose products or services may be relevant to the educational content that you will plan/present for this activity? & NO & YES  Provide details of relationship(s) below: Check all that applyCategoryDescription  Provide Names of Organizations & Relationship&Employeee.g. salesperson, marketing, or education&Royalty&Stockholder&Research Support&Speakers Bureau&Consultant&Other Section 5: HIPPA Compliance To comply with the Health Insurance Portability and Accountability Act (HIPAA), we ask that all program planners and instructional personnel insure the privacy of their patients/clients by refraining from using names, photographs, or other patient/client identifiers in course materials without the patients/clients knowledge and written authorization. I agree that my presentations will be in compliance: _____________(INITIAL HERE) Section 6: Off-Label Use (To be completed by Faculty/ Presenters/Authors) Faculty/Presenters/Authors must disclose to learners when an educational activity relates to any product used for a purpose other than that for which it was approved by the Food and Drug Administration. Faculty/Presenters/Authors discussing off-label uses:  FORMTEXT       Yes  FORMTEXT       No If yes, please list the manufacturer and the;_________________________________________ Also, If yes, please identify how the learners will be notified during the presentation: (Check all that apply)  FORMTEXT       Information provided in handouts  FORMTEXT       Information provided in audiovisuals  FORMTEXT       Other - please describe:  FORMTEXT       Section 7: Content Validation Content Validation Policy The Course Director of this activity has ensured that the content of this presentation conforms to the ACCME policy activities, which require accredited providers ensure that: All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. -45AF`defvi\vOA6h6CJ^JaJhh|Kh<CJ^JaJhh6>*䴳󴥰/䴳󴥰ܲ䴳>*䴳󴥰<CJ^JaJh\ )CJ^JaJh|Kh25CJ ^JaJ h|Kh]5CJ ^JaJ h4u5CJ ^JaJ h|Kh/5CJ ^JaJ hw5CJ hj5CJ h-&I5CJh \hw5CJ!jhw5CJUmHnHu5ef 0 p } d$If]gd6E$If^`Egd6 dd$If]^`dgd6 d]^`gd$Pdx-D@M ]Pa$gdw $*$a$gdw     . 0 2 F H J T V Z गԄगqगcXh:5CJ^JaJh6h6CJ^JaJh%jh6h6>*U^Jh%jjh6h6>*U^Jhh6h6CJ^JaJh6h6^J'jh6h6>*OJQJU^Jh%jh6h6>*U^Jhh6h6>*^Jhjh6h6>*U^Jhh6h65CJ^JaJh @ n p r 0 2 4 H J L V ŲўєŁўєnўє`Mў%j|h6h6>*U^Jhh6h6CJ^JaJh%jh6h6>*U^Jh%jh6h6>*U^Jhh6h6^Jh'jh6h6>*OJQJU^Jh%j>h6h6>*U^Jhh6h6>*^Jhjh6h6>*U^Jhh6h65CJ^JaJhh6h65CJ^JaJ 2    W> d]^`gd6}kd$$Ifl0:(  t0*644 layt: d$If]gd6Ed$If^`Egd6V X ^    0 6 V j l s_O8_-jsh|Khp>*CJU^JaJhh|Kh]>*CJ^JaJh'jh|Khp>*CJU^JaJhh>*CJ^JaJhh|Kh:CJ^JaJh|Kh/CJ^JaJh|Kh\ )5CJ^JaJh|Kh65CJ^JaJh\ )5CJ^JaJh6CJ^JaJh6h6CJ^JaJhh6h6CJ^JaJh6h6^Jjh6h6>*U^Jh l :*{:k% LhSdx*$-D@M ]^S`gd|K & F Lhd*$]gd\ ) LhSd*$]^S`gd|K d]^`gd\ )% LhSdx*$-D@M ]^S`gd6  *,@BDNPdfh|~ɼ׬׼׬qɼ׬Zɼ׬-jh|Khp>*CJU^JaJh-jGh|Khp>*CJU^JaJhh|Kh]CJ^JaJ-jh|Khp>*CJU^JaJhh|Kh]>*CJ^JaJhh|Kh/CJ^JaJh|Kh]CJ^JaJh'jh|Khp>*CJU^JaJh'jh|Kh]>*CJU^JaJh!09BJ]`cԲ~q~ddqdqZPh\ )CJ^JaJh/CJ^JaJh|Kh=<CJ^JaJh|Kh*mCJ^JaJh|KhCJ^JaJh|KhfmCJ^JaJh|Kh:CJ^JaJh|Kh/CJ^JaJh|Kh]CJ^JaJh'jh|Kh]>*CJU^JaJh'jh|Khp>*CJU^JaJh-jh|Khp>*CJU^JaJh8:xz~,.Ȳ}thUEtjhjh>*U^Jh%jhjhp>*U^Jhhjh>*^Jhhjh^J h^JjhjhPC/>*U^Jh%jhjhp>*U^JhhjhPC/>*^Jhjhjhp>*U^Jh hi^JhjhPC/^Jh|KhPC/5CJ^JaJh|Kh\ )CJ^JaJh\ )CJ^JaJh6CJ^JaJz.z/Hk 0B0dx*$]B^0gd|K% LhSdx*$-D@M ]^S`gd|K LSd*$]^S`gd,'M 0B0dd*$]B^0gdV. 00*$]^0gdPC/ 00<*$]^0gd .024HJLVXNP./0:;  񣝗{hNDhjh,'M5^J2jhjh,'M>*OJQJU^JhmHnHu%jhjh,'M>*U^Jhhjh,'M>*^Jhjhjh,'M>*U^Jh hR^J hi^J hPC/^Jhjh|K^JjhjhPC/>*U^Jh%jYhjhp>*U^JhhjhPC/>*^Jhjhjhp>*U^JhhjhPC/^J hj^J HJ^`bjlıЛБvmg^XRI9jhjh,'M>*U^Jhhjh,'M^J hi^J hPC/^Jhjh$Q^J h$Q^JhjhPC/^Jhjhj5^J hi5^JhjhPC/5^JhjhtI5^J*jhjhtI>*U^JhmHnHu%j;hjhp>*U^JhhjhtI>*^Jhjhjhp>*U^Jhh|KhPC/5CJ^JaJh,'MCJ^JaJ h,'M5^J$&(zSV " # , ? 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Providers are not eligible for ACCME accreditation or reaccreditation if they present activities that promote recommendations, treatment, or manners of practicing medicine that are not within the definition of CME, or known to have risks or dangers that outweigh the benefits or known to be ineffective in the treatment of patients. An organization whose program of CME is devoted to advocacy of unscientific modalities of diagnosis or therapy is not eligible to apply for ACCME accreditation. I agree that my presentations will be in compliance: _____________(INITIAL HERE) Section 8: Statement of Understanding I, [Insert name of Planner/Presenter] have taken every precaution to ensure that the presentation identified above will be evidence-based or based on the best available evidence and free from bias and promotion. Completion of the name and date below serves as the electronic signature of the individual completing this Conflict of Interest Form and attests to the accuracy of the information given above. Name and Credentials:  Date: Section 9: pro Nurse Planner Review The Nurse Planner is responsible for ensuring completion and review of Conflict of Interest forms completed by each planner, presenter/faculty/author, and content reviewer, to document evaluation of actual or potential bias and conflict of interest. DO NOT COMPLETE - Nurse Planner use only:Resolution of potential Conflicts of Interest check all that apply:Not Applicable - No relationship(s) with a commercial interest were disclosed Not Applicable - Relationship(s) disclosed were found not to be relevant relationship(s) (explain in NOTES below)Relevant relationship(s) with a commercial interest were identified (COI exists) ACTIONS TO RESOLVE COI:Removed individual from participating in all parts of this educational activityRevised individuals role in activity so the financial relationship was no longer relevant Not awarding contact hours for a portion or all of the educational activityReview of educational activity for evidence of integrity/absence of bias by (name)  FORMTEXT       AND:Presentation will be monitored to evaluate for commercial bias (document outcome in NOTES)Participant feedback will be reviewed to evaluate for commercial bias in the activity (document results in NOTES)Other procedure:  FORMTEXT       NOTES:  FORMTEXT      Additional concern(s) for potential for bias that were not self  reported on this form AND resolution  if applicable:  FORMTEXT      Electronic Signature: An  X in the box below serves as the electronic sig|~~"#$%&MoY :d$If]gd7N$0d<7$8$H$^0a$gd4u0<-D@M ]^0gd4u3$ Gp@ P !$`'0*-/2p5@8;=@d8$a$gd4ud7$8$H$gdj$d1$G$a$gdj$ & Fd1$G$a$gdj Qq +@:cdeƹpbTbB#h4uh4u5@B* \^Jphfh4uh4u6@\^Jh4uh4u5@\^J h4uh4u6@B*^Jph&h4uh4u56@B*\^Jphhj5CJ^JaJh4uh4u5CJ^JaJh]5CJ^JaJh4uh4uCJ^JaJ h4uh4uh4uh4u\]^Jhh4uh4u5\]^Jhh4uh4u^Jh4uh4uB*^Jph UD$d7$8$H$a$gd4ukd$$Iflh\>l$Gd*T t&644 lBayt7N$ :d$If]a$gd7N :d$Ifgd7N @:dD$ \0@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7N$0dx^0a$gd4u0<-D@M ]^0gd4udeBD$ \0@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7NxkdH$$Ifl^>D%'  t &0'44 lap &yt7NPF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7Nhkd$$Ifl6>D%' t0'44 layt7N={kd$$Ifl0>LD%    %  t0'fffff44 layt7NF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7NZrstuȃރ߃3456189:DE ھھھھq` jh4uh4u@U\^J/jh4uh4u6>*@U\]^J h4uh4u6>*@\]^J)jh4uh4u6>*@U\]^Jh4uh4u5>*@\^Jh4uh4u5@\^Jh4uh4u6@\^J#h4uh4u5@B* \^Jphf h4uh4uh4uh4u@\^J#slL$ \0Q@p@ P !$`'(0*-/2p5@8;=@CPF IQd$@&If]^Q`gd7NF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7Nstu=F$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7N{kdF$$Ifl0>LD%    %  t0'fffff44 layt7Nu6{kd$$Ifl0>LD%    %  t0'fffff44 layt7NL$ \0Q@p@ P !$`'(0*-/2p5@8;=@CPF IQd$@&If]^Q`gd7N3sF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7NF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7N3456o))F$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7Nkd$$Ifl4F>LZD%`       $  t0' ff fff f ff44 layt7N6)kd$$Ifl4F>LZD%       $  t0' f fff f ff44 layt7NF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7NlL$ \0Q@p@ P !$`'(0*-/2p5@8;=@CPF IQd$@&If]^Q`gd7NF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7No))F$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7Nkd$$Ifl4F>LZD%       $  t0' f fff f ff44 layt7N  ؆چ܆ކƇȇʇ̇(°ɢ°ɢ°ɎhO1jh4uh4u6>*@U]^JmHnHu,j\h4uh4u6>*@U]^Jh4uh4u6>*@]^J&jh4uh4u6>*@U]^Jh4uh4u6@\^J#h4uh4u5@B* \^Jphf h4uh4uh4uh4u@\^Jh4uh4u5@\^Jh4uh4u5>*@\^Jh4uh4u@\]^J"kd%$$Ifl4F>LZD%       $  t0' f fff f ff44 layt7NL$ \0Q@p@ P !$`'(0*-/2p5@8;=@CPF IQd$@&If]^Q`gd7N "؆llL$ \0Q@p@ P !$`'(0*-/2p5@8;=@CPF IQd$@&If]^Q`gd7NF$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7N؆چ܆\F$ _0L@p@ P !$`'(0*-/2p5@8;=@CPF Id$@&If]gd7Nkd$$Ifl4\>LZhD%  `      # 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