2023 ICN Summit COI 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.

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2023 CE Conflict of Interest Form

Section 1 - Demographic Data

Section 2 - Conflict of Interest

Section 3 - Statement of Understanding

INDIANA CENTER FOR NURSING

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