COMMERCIAL SUPPORT AGREEMENT

Individual Educational Activity Applicant

Commercial Supportis financial or in-kind contributions given by a ‘commercial interest’ that are used to pay for all or part of the costs ofaContinuing Nursing Education (CNE) activity.A Commercial Interest, as defined by the American Nurse's Credentialing Center (ANCC), is anyentity producing, marketing, reselling, or distributing healthcare goods or services consumed byor 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. Nonprofit orgovernment organizations, non-healthcare-related companies, and healthcare facilities are notconsidered commercial interests.

Individual Educational Activity (IEA) Applicants may accept commercial support for educational activities that they are developing. The IEA Applicant is referred to as the “provider”of the educational activity. Commercial Interest Organizations may contributecommercial support, but may not provide or co-provide a CNE activity.

The IEA Applicant acting as the provider of the educational activity is responsible for obtaining this written Commercial SupportAgreement, signed by an individual legally authorized to enter into contracts on behalf of each organization. The IEA Applicant must take responsibility for managing commercial support in adherence with ANCC criteria, documenting how commercial support was used for the educational activity or activities. All payments using commercial support funds must be made by the IEA Applicant; not the Commercial Interest Organization. The Commercial Interest Organization may request that the IEA Applicant submit a record of how commercial support funding was spent, and may request the return of unused funds.

The IEA Applicant’s CNE Nurse Planner will be responsible for assuring compliance with allstandards set forth in the ANCC’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities. It is located at or the WNA CEAP website.

Directions: Type information directly into the space provided or type an ‘X’ in the appropriate box to indicate your response. Save the completed form to your computer. Provide a copy to each organization involved.

Title of Activity:
Date(s) offered:
Location (if live event):
IEA Applicant Organization:
Address:
Representative Name:
Representative Title:
Email:
Phone:
CNE Nurse Planner:
Commercial Interest Organization:
Address:
Representative Name:
Representative Title:
Phone:
Email:

DESCRIPTION OF COMMERCIAL SUPPORT

Type(s) of commercial support provided:

Funding – Amount:
Area(s) of activity organization providing funding would like to support:
Unrestricted
Restricted*- indicate specific aspect you will support:
Speaker honoraria
Speaker expenses (travel, stay, etc.)
Learner attendance (tuition and/or travel/stay expenses)
Food for meal or break
Other:

* The commercial interest may request that funds be used to support a specific part of an educational activity. The IEA Applicant may choose to accept the restriction or not accept the commercial support.The IEA Applicant maintains responsibility for all decisions related to the activity asdescribed below.

In-kind donation – Approximate value:
Description: Describe the type and amount of materials, space, resources and/or services donated below:

TERMS AND CONDITIONS

1. / All organizations must comply with the ANCC Content Integrity Standards for Industry Support in Continuing Educational Activities which is available on the ANCC Accreditation web page.
2. / This activity is for educational purposes only and will not promote any proprietaryinterest of a Commercial Interest organization providing financial or in-kind support.
3. / The IEA Applicant is responsible for all decisions related to the educationalactivity. The Commercial Interest Organization providing financial or in-kind support may not participate in any component ofthe planning process of an educational activity, including:
  • Assessment of learning needs
  • Determination of objectives
  • Selection or development of content
  • Selection of planners, presenters, faculty, authors and/or content reviewers
  • Selection ofteaching/learning strategies
  • Evaluation methods

4. / The IEA Applicant will make all decisions regarding the disposition anddisbursement of commercial support in accordance with ANCC criteria.
5. / All commercial support associated with this activity will be given to the IEA Applicant. No other payments shall be given to anyindividuals involved with the supported educational activity.
6. / Commercial support will be disclosed to the participants of the educational activity.
7. / Commercial Interest Organizations may not recruit learners from the audience of the educational activity for any reason.
8. / Commercial Interest Organizations may not exhibit, promote or sell products orservices during the introduction of an educational activity, while the educational activitytakes place or at the conclusion of an educational activity, regardless ofthe format of theeducational activity.

STATEMENT OF UNDERSTANDING

An "X" in the boxes below serves as the electronic signatures of the representatives duly authorized to enter into agreements on behalf of the organizations listed and indicates agreement of the terms and conditions listed in the Commercial Support Agreement above.

Individual Educational Activity Applicant Organization Representative:

Name and Credentials: / Date:

Commercial Interest Organization Representative:

Name and Credentials: / Date:

April 17, 2015 1