Bio-Conflict-Of-Interest-Form - Baromedical Nurses Association printable pdf download

Bio-Conflict-Of-Interest-Form - Baromedical Nurses Association

Baromedical Nurses Association

Biographical and Conflict of Interest Form

Revised 2016

Title of Educational Activity:

Education Activity Date:

Role in Educational Activity: (Check all that apply)

Planning Committee Member

Faculty/Presenter/Author

Content Reviewer

Nurse Peer Reviewer

Other – Describe:

Section 1: Demographic Data

Name with Credentials/Degrees: ___________________________________

If RN, Nursing Degree(s):

Diploma

BSN

Masters

Doctorate

License #______________ Exp Date______

Address: _________________

Phone Number: ____________________Email Address: ___________________ ___

Current Employer and Position/Title:

Section 2: Expertise - Planning Committee

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

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

Content Expert

Other

Please describe expertise and years of training specific to the educational activity listed above. (If the

description of expertise does not provide adequate information, the Accredited Approver may request

additional documentation.)

Section 3: Expertise - Presenter/Faculty/Author/Content Reviewer

the expertise information the same as listed above.

An "X" on this line identifies

Please describe expertise and years of training specific to the educational activity listed above. (If the

description of expertise does not provide adequate information, the Accredited Approver may request

additional documentation.)

____

Section 4: Conflict of Interest

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 (see Figure 6). The Nurse

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Bio-Conflict-Of-Interest-Form - Baromedical Nurses Association