Diane Perks, DNP, CRNP
Disclosures: Nothing to disclose - 02/17/2021


This individual is:  (Check all that apply)  Administratively Responsible Person        Planning Committee Member         Presenter/Content Specialist

Instructions:                Make as many copies of this form as necessary to provide the required information documenting adherence to the criteria.  Do not send curriculum vitae. Form must be typed or word-processed.


Name, degree, and credentials:              

Home Address or Business Address:              

Day Telephone:                              Extension: 

E-mail address:                           

Present position (title):             


Educational Activity Planners: Describe your professional qualifications and familiarity with the target audience

Educational Activity Faculty/Content Specialist: Describe your knowledge and expertise in this topic area


Conflict of Interest Disclosure


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 planers and faculty must take full disclosure indicating whether the planner, faculty, or content specialist and/or his/her immediate family members have an 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 any 

                            A. Relationship with companies who manufacture products used in the treatment of the subjects under discussion

B. Relationship between the planner, faculty, or content specialist and commercial supporter(s) of the activity and/or

C. Intent to discuss unlabeled uses of a commercial product, or an investigational; use of a product not yet approved for this purpose.

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.


A.       Is there a relationship with companies who manufacture products used in the treatment of the subjects under discussion:

                                            Yes                            No     If yes, list company(ies) with relationship:


                            Relationship                                          Name of Commercial Company(ies)

              Research Support

   Speaker’s Bureau



   Other Support

   Large Gift(s)


B.       Is there a discussion of unlabeled uses?

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 provided in audiovisuals

  4. Other, please describe


C.       How will any conflict of interest be 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. Not applicable since no conflict of interest.

___ 5. Other: Describe:


All information disclosed must be shared with the audience whether on the program handouts, advertising, and/or audiovisual presentation.



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