Student Poster Presenter

Name Credentials

Address

Daytime Telephone: Email Address:

Present Position (Title) & Employer

Presenter: Describe your expertise in this topic:

Conflict of Interest Statement

ANCC defines a “conflict of interest” as when an individual has an opportunity to affect CNE content with products or services from a commercial interest with which he/she has a financial relationship. Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her immediate family members have any relationships with sources of commercial support, e.g. pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty and content specialists participating in CE activities must disclose to the audience information listed below.

A. Is there a potential conflict of interest?
Yes
No If yes, list company(ies) with relationship:

Relationship Name of Commercial Company(ies)

Research Support

Speakers’ Bureau

Consultant

Shareholder

Large Gift(s)

Other Support

B. If there is conflict of interest, how has it been resolved?

1. Have discussed this conflict with individual who is now aware of and agrees to our policy.

2. Presenter has signed a statement that says s/he will present information fairly and without bias.

3. RN with minimum of BSN or designee will monitor session to ensure conflict does not arise.

4. Other: Describe:

C. Discussion of off-labeled uses:
Yes
No

If yes, you must disclose this information during your presentation. How will you do this?

1. Verbal statement during the presentation.

2. Information provided on handouts.

3. Information provide in audiovisuals (slides, overhead, PowerPoint, etc.)

4. Other: Describe: