STN Identification of Financial Relationship

Educational Activity Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

STN Educational Activities

STN Educational Activities {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Check all that apply

Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please describe

Role in Educational Activity

Role in Educational Activity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Check all that apply

Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please describe

Committee Membership

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Check all that apply

Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please describe

Section 1: Demographic Data

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Credentials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If RN, Nursing Degree(s): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Check all that apply

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Current Employer and Position/Title: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Section 2: Identification of Financial Relationship

The potential for bias 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 any financial relationships and resolving any potential bias during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential bias, 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 the content integrity document )

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.

If yes, please include the description of the relationship for each category below.

* *All financial relationships, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.

Salary {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Royalty {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Stock {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Speakers Bureau {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Consultant {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Section 3: Statement of Understanding

Checking the box below serves as the electronic signature of the individual completing this Biographical/Identification of Financial Relationship Form and attests to the accuracy of the information given above.

I attest to the accuracy of the information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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STN Identification of Financial Relationship

Educational Activity Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

STN Educational Activities

STN Educational Activities {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Role in Educational Activity

Role in Educational Activity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Committee Membership

Committee Membership {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Section 1: Demographic Data

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Credentials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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If RN, Nursing Degree(s): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Current Employer and Position/Title: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Section 2: Identification of Financial Relationship

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.