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Indiana Nursing Workforce
Workforce Data Reports
Nursing Minimum Data Set
Strategic Initiatives
2021 Online Indiana Nursing Summit: One Voice
Research Initiative
IN Nurse-Led Research Compendium
Indiana NEEDS Initiative
Indiana NEEDS Initiative Toolkits
NEEDS2B Program
Education–Council of Indiana Nursing Deans and Directors (CINDD)
Indiana Action Coalition
Nursing Leadership
Nursing Practice
Scholarship Program
Be a Nurse
Licensed Practical Nursing
Registered Nursing
Nursing as a Second Career
Preparing in High School
Men in Nursing
Nursing Education
Indiana Schools of Nursing Accredited by CCNE, ACEN or CNEA
Accreditation
Accelerated Programs
LPN Specialty Certification
RN Specialty Certification
Financial Aid
LPN & RN Refresher Programs
Resources
2021 Virtual Resiliency Series
Nursing Organizations
RN Transition-to-Practice Toolkit
Career Counseling
Upcoming Events
2021 Online Indiana Nursing Summit: One Voice
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2022 ONA COI Form
2022 ONA Conflict of Interest Form
Section 1 - Demographic Data
Please Note: Your name, credentials, title etc. will appear on the agenda with the spelling and format in which you submit them on this form.
Name
*
First
Last
Degrees/Credentials
*
Email
*
Enter Email
Confirm Email
Employer
*
Position / Title
*
Your role in Indiana Nursing Summit
*
Check all that apply
Faculty/Presenter/Author
Planning Committee Member
Other
Section 2 - 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. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity.
*Commercial interest, as defined by ANCC, 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. Please reference content https://z9m.f77.myftpupload.com/wp-content/uploads/2020/02/accred-cecontentintegrity.pdf
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, 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 spouse/partner?
*
Yes
No
If YES, Please complete the table below by describing all actual, potential or perceived conflicts of interest. Describe all that apply.
Salary
Royalty
Stock
Speakers Bureau
Consultant
Other
Section 3 - Statement of Understanding
E-Signature
*
Completion of the section below serves as the electronic signature of the individual completing this Conflict of Interest Form and attests to the accuracy of the information given above.
First
Last
Suffix