Biographical & Conflict of Interest Form

Disclosing a relevant financial relationship with an organization does not preclude involvement in the development, management, presentation, or evaluation of a CE activity. However, the Course Director must have resolved any conflict(s) of interest and the audience must be informed of all such relationships prior to the start of the activity. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners, faculty, moderators, and panelists must make full disclosure indicating whether they, and/or a spouse or domestic partner, have had any relevant financial relationships with commercial interests within the last 12 months. A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients (excepting non-profits, government organizations or providers of clinical service directly to patients). Individuals who refuse to disclose will be disqualified from participation in the CME activity. Failure to complete and return the form is the same as refusing to disclose.)
Faculty, Speaker, Author or Planning Committee Member Name * Required
First Last
Faculty, Speaker, Author or Planning Committee Member Email * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credentials/Degrees * Required
If RN, Nursing Degree(s):
- Diploma
- ADN
- BSN
- Master's Degree
- APRN
- DNP
- PhD
Please list your administrative assistant's name and contact information (if applicable)
Administrative Assistant's Name (if applicable):
First Last
Admin Asst's Email:
Admin Assistant's Phone:
(###)###-####
Upload CV or Resume
Max. file size: 74 MB.
Please upload your most current CV/resume
Head shot for promotional purposes
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Please upload an image of yourself for use in promotional materials.

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.

*Commercial interest, as defined by ACCME, ANCC and ACPE, is any entity producing, marketing, reselling, 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, resells, or distributes healthcare goods or services consumed by or used on patients (excepting non-profits, covernment organizations or providers of clinical services directly to patients).

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, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. 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 the participants/learners prior to the start of the educational activity.

**Relevant relationships, as defined by ANCC, ACPE and ACCME are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.
- Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.
- Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
- Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.
Is there an actual, potential or perceived conflict of interest for yourself or immediate family member or domestic partner? * Required
- Yes
- No
If yes, please designate below for all actual, potential or perceived conflicts of interest**: (Select all that apply)
- Salary
If you have a SALARY conflict of interest, please indicate the name of the company(s) and your role for each company.
- Royalty
If you have a ROYALTY conflict of interest, please indicate the name of the company(s) and your role for each company.
- Stock
If you have a STOCK conflict of interest, please indicate the name of the company(s) and your role for each company.
- Speakers Bureau
If you have a SPEAKERS BUREAU conflict of interest, please indicate the name of the company(s) and your role for each company.
- Consultant
If you have a CONSULTANT conflict of interest, please indicate the name of the company(s) and your role for each company.
- Grants/Research
If you have a GRANTS RESEARCH conflict of interest, please indicate the name of the company(s) and your role for each company.
- Property Rights
If you have a PROPERTY RIGHTS conflict of interest, please indicate the name of the company(s) and your role for each company.
If a conflict of interest exists, you will be contacted by the course planners to determine how to resolve the conflict.

Treatment Recommendations and Research Citations: If you make treatment recommendations or reference scientific research as part of your presentation, please note that all studies and evidence must be referenced on presentation slides or handouts.
By typing your name or uploading your electronic signature below, you are attesting that all clinical recommendations are based on evidence that is accepted within the profession of medicine and all scientific research referred to, reported, or used in support of or justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection and analysis.
You are also attesting to the accuracy of the information submitted in this Biographical & Conflict of Interest Form.
Upload your electronic signature: (If available)
Max. file size: 74 MB.
Please type your name and credentials below: * Required
Email * Required
Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY

Biographical & Conflict of Interest Form - 2014-2015 Department of OB/GYN

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