NMNA Accredited Approver Unit
THE Nurse Planner Biographical and Conflict of Interest Form 2013 Criteria Revised 09/01/2015
Title of Educational Activity:
Education Activity Date:
Role(s) in Educational Activity: (Check all that apply)
Nurse Planner accountable for meeting ANCC criteria
Presenter/Author
Content Expert
Section 1: Demographic Data
Name with Credentials/Degrees: _
_
If RN, Nursing Degree(s)(all that apply):
Phone Number: _
_
Diploma
AD
BSN
Masters
Doctorate
Email Address: _
Current Employer and Position/Title: _
Section 2: Expertise is
If a planning committee member, select area of expertise specific to the educational activity listed above:
Nurse Planner is actively licensed and has a minimum of a Baccalaureate of Science in Nursing degree.
Content Expert
Other (explain):
Please describe expertise and years of training specific to your role as Nurse Planner in this educational activity. (If the
description of expertise does not provide adequate information, the Accredited Approver may request additional
documentation.)
Section 3: Expertise - Presenter/Author
An "X" in this box identifies the expertise information is the same as listed above ONLY if both Planner & Presenter.
Please describe expertise and years of training specific to the educational activity listed above. (If the description of
expertise does not provide adequate information, the Accredited Approver may request additional documentation.)
Section 4: Conflict of Interest
Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?
If yes, complete the table below for all actual, potential or perceived conflicts of interest**:
Check all that
apply
Category
Yes
No
Description
Salary
Royalty
Stock
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 (to be completed by Nurse Planner)
Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply)
Not applicable since no conflict of interest
Removed individual, with conflict of interest, from participating in all parts of the educational activity.
Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the
educational activity.
Not awarding contact hours for a portion or all of the educational activity.
Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in
presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring
the educational activity to evaluate for commercial bias in the presentation.
Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in
presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing
participant feedback to evaluate for commercial bias in the activity.
Other - Describe:
Section 6: Confirmation/approval of veracity of biographical/COI information.
Note to Nurse Planner: if you or administrative person is transferring information on speakers from resumes or C.V.s,
the presenter/author must have an opportunity to review what was typed onto the form for accuracy, and have
verified this with you before the document is “signed.”
I confirm I was provided the Definition of Financial/Conflict of Interest when completing my Bio/COI form.
I confirm that the information reported above is accurate. I understand that this information will be disclosed
publicly in conference materials or publications, where appropriate. I further understand that the program provider
reserves the right to replace me in an educational program, decline to publish my work, or otherwise limit my
participation in this particular activity if they believe that significant conflict of interest exists. I agree to notify the
program provider if there is any change in the information that I have provided regarding my financial relationships prior
to the educational program or publication of my work.
Please type your name and credentials in the electronic signature box. This will act as your electronic signature
E-signature
Date
Name, credentials
____________________________________________________________________________________________
Nurse Planner Signature:
Someone other than the nurse planner must evaluate the nurse planner’s Bio/COI
for conflicts of interest.
An X in the box below serves as the electronic signature of the Nurse Planner reviewing this Bio/COI form for content
and conflict resolutions required on this Bio/COI form.
Electronic signature
Date completed
Name, Credentials