InfoPath Form Web Part


Biographical Information

Please complete the form. Once completed, click 'submit' to send your information to PCMC.
Submitter Name*
Nursing Degree
Select highest degree completed

Person Type

Street Address
Zip Code
Telephone ext
Familiarity With Audience

Planner, Faculty and Content Specialist Conflict of Interest Statement

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. If the applicant already has special forms to identify this, it does not need to be repeated on this form. Include the applicant's copy of the completed forms declaring vested interest. All planners, faculty, and content specialists participating in CE activities must disclose to the audience any:
  • Relationship with companies who manufacture products used in the treatment of the subjects under discussion
  • Relationship between the planner, faculty or content specialist and commercial supporter(s) of the activity and/or
  • Intent to discuss unlabeled uses of a commercial product, or an investigational use of a product not yet approved for this purpose.
In order to ensure balance, independance, 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 manufactureres and/or corporations whose product or services are related to pertinent therapeutic areas.
Conflicts of Interest

Off Label Product Use

Financial Conflicts of Interest

These questions are intended to identify, resolve and disclose financial conflicts of interest, and to that end, we need to know if ANY of these personal relationships with a financially-interested company (that is, a company with products or services directly related to the topic under discussion) apply to the presenter or spouse/partner. If the answer to any one of these questions is "yes", Debbie Bemel will need to ask for additional details about the nature of the relationship.
Have any royalty, stock, or financial interest of any other type involving a financially-interested company, excluding any mutual fund stocks and/or blind trusts which you might hold?

Serve as an officer or any other position in any financially-interested company?

Faculty Disclosure of Relevant Financial Relationships

CME Activity Content

Title of Presentation(s)

Do you have any relevant financial relationships with any commercial interests?

Electronic Signature*
Type your full name in the box to sign this form
Content Type
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