Biographical Data Form

VIRGINIA NURSES ASSOCIATION

CONTINUING EDUCATION APPROVAL COMMITTEE

BIOGRAPHICAL DATA FORM

FORM C

THE MODERATOR FOR YOUR SESSION WILL USE THE BELOW HIGHLIGHTED INFORMATION FOR YOUR INTRODUCTION. PLEASE MAKE SURE YOU COMPLETE THE ENTIRE FORM AND MAKE SURE THE HIGHLIGHTED AREAS ARE HOW YOU WOULD LIKE TO BE INTRODUCED!

Name (as you wish to be presented),
Degrees & Credentials:
If RN, nursing degrees(s): AD Diploma BSN MSN Doctorate
Address:
Day Telephone:
Email Address:
Current Employer/Organization:
Position/Title:
Role in Educational Activity: (Check all that apply)
Planning Committee Member
Faculty/Presenter/Author
Content Reviewer
Other – Describe:
Session Title:
Conflict of Interest Statement for all Planners, Faculty and Content Specialists/Contributors
The potential for conflicts of interest 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. Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, 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, resells, or distributes healthcare goods or services consumed by or used on patients.
All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

SECTION 1: EXPERTISE: PLANNING COMMITTEE

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

Nurse Planner (responsible for ensuring adherence to ANCC Accreditation criteria)

Content Expert

Other

a. In a short paragraph, please describe expertise and years of training specific to the educational activity. (i.e. planning CE, content area, years of experience) Do not only state years of experience:

SECTION 2: EXPERTISE: PRESENTER/FACULTY/AUTHOR/CONTENT REVIEWER

1. Check the best description:

In addition to being a presenter/faculty/author/content reviewer, I am also a planner.

Expertise information is the same as above.

I am only a presenter/faculty/author/content reviewer (please also complete Section 2, number 2).

2. Please provide a short bio that describes your expertise and years of training specific to the educational activity (i.e. years of experience in content area and other information you would like the session moderator to use for your introduction):

SECTION 3: CONFLICTS OF INTEREST

1. Is there an actual, potential or perceived conflict of interest for yourself or

spouse/partner?

Yes – Describe below: (Check all that apply)

Type of Relationship Describe

Salary

Royalty

Stock

Speakers Bureau

Consultant

Research Support

Large Gift(s)

Other:

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

2. Do you/your spouse/partner have a relationship with the commercial supporter of the

activity?

No (Not applicable--no commercial support; OR no relationship with supporter)

Yes – List companies and relationships below:

Type of Relationship Commercial Supporter

3. Do you have a potentially biasing relationship of personal nature that can impact this educational activity? (For example: personal or religious beliefs, close friend relationship with organizer, husband-wife relationship)

Yes – If yes, please describe:

4. Do you have a potentially biasing relationship of professional nature that can impact this educational activity? (For example: manager-employee relationship, professor-student relationship)

Yes – If yes, please describe:

5. As the planner / presenter / faculty / author / content specialist/ content reviewer whosesignature appears below, I attest that the information disclosed on this form is accurate. I agree to present any information that might represent a potential conflict of interest fairly and without bias:

Agree

Disagree

Signature:

Date:

By checking this box, I am providing my electronic signature approving all the information entered above (please enter name and date on signature and date lines above)

______

Section to be Completed by Nurse Planner ONLY

**Note: If this form is for the activity Nurse Planner, an individual other than the nurse planner must review and sign this form.

After review of this bioform, is there a potential COI or bias present?

No. Not applicable since no COI or bias

Yes. Describe the procedures used to resolve COI or bias on the following page 4.

The electronic signature of the Nurse Planner reviewing the content of this bioform:

Signature: Date:

By checking this box, I am providing my electronic signature approving all the information entered above (please enter name and date above)

Section to be Completed by Nurse Planner

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

Removed individual, with COI or bias, from participating in all parts of 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:

Reflects ANCC 2013 Manual.

Virginia Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

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