DISCLOSURE OF RELEVANTFINANCIAL RELATIONSHIPS

Relative to the educational activity under discussion, allplanners, presenters, speakers, and content experts must disclose, prior to the activity, whether or notthey or their spouse/partner have any relevant financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

  • A financial relationship exists when the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. This includes financial relationships of your spouse or partner.
  • Relevant financial relationships are financial relationships in any amount occurring within the past 12 months that create a conflict of interest.
  • Control in planning or presenting educational content exists when somebody has influence in the process of needs assessment, faculty selection, curriculum development, or evaluation of an educational activity.

CE Activity or Meeting: / CSC File #
Your Name & Credentials:
Your Role In this Activity: / Planner / Faculty/Speaker / Content Expert/Target Audience
Please check one of the following two boxes. Currently or in the past 12 months:
I (and spouse/partner/immediate family members) do not have any relationships with any commercial interests.
I (andspouse/partner/immediate family members) do have relationships with commercial interests with products and services. The financial relationships are as follows:
Nature of Affiliation / Financial Interest / Name and Description of Commercial Interest
Receipt of Honorarium or Expenses for this Lecture
Consultant
Speakers Bureau
Major Stock Shareholder
Researcher
Other Financial or Material Interest
Please attest to the following by marking this box
I will verbally identify or display on handouts or visual aidsany “off label” or investigational uses described for any medications discussed. Further, when discussing specific medications, I will use generic names, and/or if I mention trade names, I will mention the trade names of similar products from all manufacturers.
► By typing or signing my name below, I hereby attest that the information provided in this document is legitimateand true to the best of my knowledge.
Signature: / Date:
To be completed by the CE Coordinator:
Information from this form was included in the preconference publicity.
Information from this form was disclosed in the course materials (i.e., final program, faculty’s opening slide, etc.)
Reviewed by CSC:______Date:______
  • Conflict of interest can exist when somebody is in control of education content incorporating information about products or services of a commercial interest with which he/she/spouse/partner has a financial relationship.

BIOGRAPHIC DATA FORM

NAME & CREDENTIALS:
PRESENT POSITION/TITLE:
BUSINESS ADDRESS:
CONTACT INFORMATION:
Business Telephone Number / Fax Number / Email Address
EDUCATION: (Include basic preparation through highest degree held)
DEGREE
(BSN, MSN, etc.) / INSTITUTION
(Name/City/State) / MAJOR AREA OF STUDY / YEAR DEGREE AWARDED
1.
2.
3.
4.
BRIEF BIOGRAPHICAL INFORMATION: Please do not attach resumes or CVs in lieu of completing this section. (In no more than 100 words, describe your professional experience or areas of continuing education expertise which contribute to your involvement in THIS particular continuing education activity. This might include your educational background, publications, or experience.)

Last Update: Feb 2015Page 1 of 2