Boston College William F. Connell School of Nursing
Continuing Education Program

Continuing Education activities are intended to serve the public interest and to comply with ANCC standards for accreditation. To this end, it is the policy of the Boston College School of Nursing Continuing Education Program that all educational programs are balanced, scientifically rigorous, objective, and independent of commercial influence.

The purpose of this form is to identify and resolve all potential conflicts of interests that arise from financial relationships with any commercial* or proprietary entity that produces healthcare-related products and/or services relevant to the content you are planning, developing, or presenting for this activity. This includes any financial relationships active within the last 12 months, as well as known financial relationships of your spouse or partner.

Your Name:

Role in Activity:

Please check one of the boxes on behalf of yourself and your spouse/partner:

1st Commercial Entity

2nd Commercial Entity (if necessary)

3rd Commercial Entity (if necessary)

* For the purpose of this form, do not consider an entity which provides clinical service directly to patients to be a commercial entity.

**Type of relationship may include full or part time employment; status as an independent contractor, consultant, research or other grant recipient, paid speaker of teacher; membership on advisory committees or review panels; ownership interest (product royalty/licensing fees, owning stocks, shares, etc); or any other financial relationship.

By submitting this form, I state that the information above is correct to the best of my knowledge.