Bio-Conflict-Of-Interest-Form - Baromedical Nurses Association Page 4

Section 6: Statement of Understanding

An “X” in the box below serves as the electronic signature of the individual completing this

Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

_____

Electronic Signature (Required)

_____ _____________________________ Date__________________

Completed By: Name and Credentials

Nurse Planner Signature

(* If form is for the activity Nurse Planner, an individual other than

the Nurse Planner must review and sign the form).

An “X” in the box below serves as the electronic signature of the Nurse Planner reviewing the

content of this Biographical/Conflict of Interest Form

___Electronic Signature (Required)

_________________________________________________

_________

Completed By: Name and Credentials

Date

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