Course Number list as applicable for CME/CE
Saint Louis University Continuing Education CME/CE Collection Form
Biographical and Conflict of Interest Form
Title of Educational Activity: ____________________________________________________________
Education Activity Date:
____________
Role in Educational Activity: (Check all that apply)
My ro Role on the planning committee is: (Check all that apply)
Planner Discipline ______________
Content Expert
Planning Committee Member
Target Audience
Adherence to Educational Design Criteria as
applicable
Faculty/Presenter/Author
Section 1: Demographic Data/Brief Bio
Name_____________________________________________________________________________
Credentials/Degrees:
Address: ___________________________________________________________________________
Phone Number: ______________________________
Email Address: ________________________
Current Employer and Position/Title: _____________________________________________________
Education: (include basic preparation through highest degree held)
Degree
Institution (Name, City, State)
Major area of study
Year Degree Awarded
1.
________________________________________________________________________________
2.
________________________________________________________________________________
3.
________________________________________________________________________________
Section 2: Expertise - Planning Committee
If you are a planning committee member, select area of expertise specific to the educational activity listed above:
Knowledge about the CE Process
Other
Content Expert
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Please describe expertise and years of training specific to the educational activity listed above. (If the description of
expertise does not provide adequate information, additional documentation may be requested.)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
An "X" on this line indicates that a CV is on file with SLU SON Department of Continuing Nursing Education
and/or the SLU CME Office
Section 3: Expertise - Presenters/Faculty/Authors
An "X" on this line identifies the expertise information is the same as listed above.
Please describe expertise and years of training specific to the educational activity listed above. (If the description of
expertise does not provide adequate information, additional documentation may be requested.)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
An "X" on this line indicates that a CV is on file with SLU SON Department of Continuing Nursing Education
and/or the SLU CME Office
Section 4: Conflict of Interest
Each individual who is in a position to control the content of an education activity must disclose all relevant
relationships with any entity in a position to benefit financially from the success of the CME/CNE activity.
Examples of relevant relationships include (but are not limited to) those relationships in which the individual
benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest
(e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial
benefit. Relevant relationships can also include ‘contracted research’ where the institution receives a grant and
manages the grant funds and the individual is the principal or a named investigator on the grant. Financial
benefits are usually associated with roles such as employment, management position, independent contractor
(including contracted research), consulting, speaking, teaching, membership on advisory committees or review
panels, board membership, and other activities from which remuneration is received or expected.
ACCME and the ANCC considers relationships of the individual involved in the continuing nursing education
activity to include financial relationships of the individual’s spouse/partner. ACCME and ANCC considers
relationships occurring within the 12 months prior to the implementation date of the activity as “relevant” to
conflict of interest. When a person divests himself/herself of a relationship, it ceases to be a conflict of interest
but it must be disclosed to the learners for 12 months after the termination of the relationship. All information
disclosed must be shared with the participants/learners on program handouts, advertising and/or audiovisual
presentation.
Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?
Yes
No
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If yes, complete the table below for all actual, potential or perceived conflicts of interest**:
Please check all
that apply
CATEGORY
DESCRIPTION – Provide Names of Organizations only
Employee
Royalty
Stockholder
Research Support
Speakers Bureau
Consultant
Other
** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation
of the continuing nursing education activity.
Section 5: Conflict Resolution
A. Procedures used to resolve conflict of interest or potential bias if applicable for this activity:
(Check all that apply)
Not applicable, no conflict of interest exists.
I have discussed the conflict with the SLU accrediting staff and the Nurse Planner (if applicable)
for this activity and I am now aware of and agree to the commercial support/sponsorship
policy/procedure.
I agree to provide presentation slides by the deadline in order for the COI review process to be
completed in time for approval and/or required changes.
In conjunction with the above, the Nurse Planner or designee will monitor the session to ensure
conflict does not arise.
Other - Describe:
Section 6: Off-Label Use (To be completed by Faculty/ Presenters/Authors)
Faculty/Presenters/Authors must disclose to learners when an educational activity relates to any
product used for a purpose other than that for which it was approved by the Food and Drug
Administration.
Faculty/Presenters/Authors discussing off-label uses:
Yes
No
If yes, please list the manufacturer and the;_________________________________________
Also, If yes, please identify how the learners will be notified during the presentation: (Check all that apply)
Information provided in handouts
Information provided in audiovisuals
Other - please describe:
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Section 7: 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)
_______________________________________________
Completed By: Name and Credentials
___________________
Date
Section 8: HIPPA Compliance
To comply with the Health Insurance Portability and Accountability Act (HIPAA), we ask that
all program planners and instructional personnel insure the privacy of their patients/clients by
refraining from using names, photographs, or other patient/client identifiers in course
materials without the patient’s/client’s knowledge and written authorization.
I agree that my presentations will be in compliance :_____________(INITIAL HERE)
Section 9: Content Validation
Content Validation Policy
The Course Director of this activity has ensured that the content of this presentation conforms
to the ACCME policy activities which require accredited providers ensure that:
1. All the recommendations involving clinical medicine in a CME activity must 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.
2. All scientific research referred to, reported or used in CME in support or justification of
a patient care recommendation must conform to the generally accepted standards of
experimental design, data collection and analysis.
3. Providers are not eligible for ACCME accreditation or reaccreditation if they present
activities that promote recommendations, treatment, or manners of practicing
medicine that are not within the definition of CME, or known to have risks or dangers
that outweigh the benefits or known to be ineffective in the treatment of patients. An
organization whose program of CME is devoted to advocacy of unscientific modalities
of diagnosis or therapy is not eligible to apply for ACCME accreditation.
I agree that my presentations will be in compliance :_____________(INITIAL HERE)
SLU School of Nursing Nurse Planner Signature:
An “X” in the box below serves as the electronic signature of the Planner reviewing the content of this
Biographical/Conflict of Interest Form.
Electronic Signature (Required)
_______________________________________________
Completed By: Name and Credentials
____________________
Date
Approved Provider Biographical Data & Conflict of Interest Form Revised 3/2015
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