HCAM & MCAL Educational Program Conflict of Interest

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* 1. For this educational program, I am a...

Please select any applicable:

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* 2. Name & Credentials (Please include all relevant credentials & licensures. Ex: BSN, RN, LNHA, RAC-CT):

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* 3. Current Position/Title:

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* 4. Current Employer/Organization:

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* 5. Relation to Employer/Organization (Please select the most applicable description of your relationship to your employer/organization):

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* 6. Preferred Contact E-mail:

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* 7. Secondary/Alternate Contact E-mail (can be an assistant/secretary's contact info):

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* 8. Business Phone:

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* 9. Cell Phone (emergencies only):

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* 10. Fax:

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* 11. Preferred Mailing Address:

Please thoroughly review the following information below on Conflict of Interest & ANCC Definitions and then complete questions 15-18. Your signature and date are required.
Determining Conflict of Interest & ANCC Definitions
Commercial Interest: As defined by ANCC, is any entity producing, marketing, re-selling, 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, re-sells or distributes healthcare goods or services consumed by, or used on, patients. Nonprofit or government organizations, non-healthcare-related companies, healthcare facilities, and group medical practices are not considered commercial interests.
  • Employees or representatives of a commercial interest may not serve as planners of an educational activity, although they may be eligible to serve as faculty as long as any potential conflict of interest is resolved.
Conflict of Interest (COI): As defined by ANCC, is an affiliation or relationship of a financial nature with a commercial interest organization that might affect a person's ability to objectively participate in the planning, implementation or review of a learning activity.
  • The potential for Conflict of Interest (COI) 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. Actions must be taken prior to the start of the educational activity to resolve any potential or actual COI for anyone who may control educational content, including but not limited to planners, presenters, authors, content reviewers and/or other faculty.
Relevant Relationships: As defined by ANCC, are relationships that are expected to result in financial benefit from a commercial interest organization, the products or services of which are related to the content of the educational activity. Such relationships include employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, researcher role, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected. Evidence of remuneration includes but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honorarium, ownership interest (stock and stock options), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
  • 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. 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 participants prior to the start of the educational activity. Any relevant relationships with a commercial interest on the part of one's self or a spouse/partner must be disclosed.

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* 12. Are you currently employed by or do you represent any commercial interest organization(s)?

Please select one:

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* 13. Over the past 12 months, have you or your spouse/partner had a financial relationship with a commercial interest whose products or services may be relevant to the educational content that you will plan/present for this activity?

Please select one:

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* 14. Content Integrity Statement:  Do you agree to ensure to the best of your ability that content for this educational activity is evidence-based or based on the best-available evidence, is presented free from bias, and does not promote the products or services of any individual practitioner or organization?

Please select one:

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* 15. Statement of Understanding & Signature: With my signature, I attest to completing this Conflict of Interest Form in its entirety and attest to the accuracy of the information provided.

Please provide electronic signature with date.

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