CENTER FOR CONTINUING EDUCATION
COLLEGE OF NURSING - CONTINUING NURSING EDUCATION
CONFLICT OF INTEREST DISCLOSURE FORM
SECTION 1 (required reading)
In compliance with the
Accreditation Council for Continuing Medical Education
(ACCME) Standards for Commercial Support of Continuing
Medical Education, and the American Nurses Credentialing
Center (ANCC) requirements, it is the policy of the UNMC
Center for Continuing Education and UNMC College of Nursing
Continuing Nursing Education to ensure balance,
independence, objectivity, and scientific rigor in all UNMC
CCE and UNMC CON CNE sponsored continuing education (CE)
All persons involved in the
planning/content development are expected to disclose all
relevant financial relationships with pharmaceutical
companies, biomedical device manufacturers or distributors,
or others whose products or services may be considered
related to the subject matter of the educational activity.
Disclosure of these
relationships will be included in all written activity
materials, and mentioned verbally at the activity so that
participants may formulate their own judgments in
interpreting content and in evaluating recommendations.
Failure or refusal to disclose will prohibit
author/editor/moderator/planner/presenter from presenting at
or participating in the planning of this activity.
SECTION 2 (required input)
Please provide the following
information regarding financial relationships that you or
your spouse/partner currently hold, or have held within the
last 12 months with commercial interests that manufacture
or provide goods or services which are related to the
subject of your presentation/participation in this
I/We have no financial relationships
with a commercial entity producing healthcare related
products and/or services. (PROCEED TO SECTION 4)
The commercial entities with which
I/we have financial relationships do not produce
healthcare related products and/or services relevant to
the content I am planning, developing, or presenting for
this activity. (PROCEED TO SECTION 4)
I/We have financial relationships
with commercial entities that produce healthcare related
products and/or services relevant to the content I am
planning, developing, or presenting for this activity.
(PROCEED TO SECTION 3)
SECTION 3: (Please complete if applicable)
NATURE OF RELEVANT FINANCIAL
RELATIONSHIP: Employee, Grants/Research Support
Recipient, Board Member, Advisor or Review Panel Member,
Consultant, Independent Contractor, Stock Shareholder
(excluding mutual funds), Speakers' Bureau, Honorarium
Recipient, Royalty Recipient, Holder of Intellectual
Property Rights, or Other.
SECTION 5: (required input)
Please initial each statement
below to indicate your willingness to comply. If the
statement is not applicable, please choose N/A.
I have disclosed to the UNMC CCE and
UNMC CON CNE all relevant financial relationships, and I
will disclose the information to learners verbally (for
live activities) and in print.
The content and/or presentation of
the information with which I am involved will promote
quality or improvements in healthcare and will not
promote a specific proprietary business interest of a
commercial interest. Content for this activity, including
any presentation of therapeutic options, will be
well-balanced, evidence-based, and unbiased.
I have not and will not accept any
honoraria, additional payments, or reimbursements beyond
that which has been agreed upon directly with the UNMC
CCE and the UNMC CON CNE.
I understand that the UNMC CCE
and/or UNMC CON CNE may need to review my presentation
and/or content prior to the activity. Hence, I will
provide educational content and resources in advance as
If I am presenting at a live event,
I understand that a CME monitor will be attending the
event to ensure that my presentation is educational, and
not promotional in nature.
If I am providing recommendations
involving clinical medicine, these will be based on
evidence that is accepted within the profession of
medicine as adequate justification for their indications
and contraindications in the care of patients. All
scientific research referred to, reported, or used in CME
in support of justification of a patient care
recommendation will conform to the generally accepted
standards of experimental design, data collection, and
If I am discussing specific health
care products or services, I will use generic names to
the extent possible. If I need to use trade names, I will
use trade names from several companies when available,
and not just trade names from any single company.
If I am discussing any product use
that is off-label, I will disclose during the
presentation that the use or indication in question is
not currently approved by the FDA for labeling or
If I have been trained or utilized
by a commercial entity or its agent as a speaker (e.g.,
speaker's bureau) for any commercial interest, the
promotional aspects of that presentation will not be
included in any way with this activity.
If I am presenting research funded
by a commercial company, the information presented will
be based on generally accepted scientific principles and
methods, and will not promote the commercial interest of
the funding company.
I agree to comply with the
requirements to protect health information under the
Health Insurance Portability and Accountability Act of
SECTION 6: DECLARATION (required input)
I will uphold academic
standards to ensure balance, independence, objectivity,
and scientific rigor in my role in the planning,
development, or presentation of this CME activity.
I will support content
and clinical recommendations with the best evidence
available from all sources.
I will inform learners when I discuss
or reference investigational or off-label use
of therapeutic agents or product
By selecting this box, I signify that I
understand the above in its entirety and
agree to the declarations above.