Diane Perks, DNP, CRNP
Disclosures: I/we have no financial relationships to report.

                 Children’s Hospital of Philadelphia

Biographical and Conflict of Interest Form

 

Title of Educational Activity:              Templeton Conference Planning Committee

            Education Activity Date:              March1-2, 2019

             

            Role in Educational Activity: (Check all that apply)                            X  Planning Committee Member

                                                                                                                                               Faculty/Presenter/Author

                 Content Reviewer

                                                                                                                                               Other – Describe:             

 

Section 1:  Demographic Data

Name with Credentials/Degrees Diane H. Perks, DNP, CRNP

 

If RN, Nursing Degree(s):  AD   Diploma  BSN   Masters   X Doctorate

 

Address: 1077 Lavera Road, Warminster, Pa. 18974

Phone Number: 267-234-1141                              Email Addressperksd@email.chop.edu

 

Current Employer and Position: Children’s Hospital of Philadelphia, Trauma Nurse Practitioner

 

Section 2:  Expertise - Planning Committee

 

If a planning committee member, select area of expertise specific to the educational activity listed above:                                         Nurse Planner (responsible for ensuring adherence to ANCC Accreditation criteria)

                            X  Content Expert

                            X  Other

 

Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the Accredited Approver may request additional documentation.)

 

              Diane H. Perks, DNP, CRNP is the Trauma Program Manager and also a Nurse Practitioners in the Trauma Program at CHOP.   She has over 37 years of pediatric nursing experience primarily in emergency/trauma and critical care and has held numerous positions in both clinical and administrative roles during her career.               

              Professionally, Diane has lectured on numerous pediatric topics (regionally/nationally) with specific expertise on pediatric trauma topics. She has authored pediatric trauma articles and is a member of numerous professional organizations.

 

              Diane received her BSN and MSN at Temple University in Philadelphia and her Doctorate of Nursing Practice (DNP) at Jefferson University in Philadelphia.

 

__________________________________________________________________________________

Section 3: Expertise - Presenter/Faculty/Author/Content Reviewer

 

   An "X" on this line identifies the expertise information the same as listed above.

 

Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the Accredited Approver may request additional documentation.)

             

             

 

 

Section 4: 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 (see Figure 6). 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.

Commercial Interest Organizations are ineligible for accreditation.

 

An organization is NOT a Commercial Interest Organization* if it is:

  • A government entity;
  • A non-profit (503(c)) organization;
  • A provider of clinical services directly to patients, including but not limited to hospitals, health care agencies and independent health care practitioners;
  • An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to providers or developers of electronic health information systems, database systems, and quality improvement systems;
  • A non-healthcare related entity whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on patients.
  • Liability insurance providers
  • Health insurance providers
  • Group medical practices
  • Acute care hospitals (for profit and not for profit)
  • Rehabilitation centers (for profit and not for profit)
  • Nursing homes (for profit and not for profit)
  • Blood banks
  • Diagnostic laboratories

(*Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 (www.accme.org) - ANCC’s definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition)

 

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              X  No

 

 

 

If yes, complete the table below for all actual, potential or perceived conflicts of interest**:

 

 

Check all that apply

Category

Description

 

Salary

 

 

Royalty

 

 

Stock

 

 

Speakers Bureau

 

 

Consultant

 

 

Other

 

 

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

 

 

 

Section 5:  Conflict Resolution  (to be completed by Nurse Planner)

 

  1. Procedures used to resolve conflict of interest or potential bias if applicable for this activity:

(Check all that apply)

X  Not applicable since no conflict of interest.

  Removed individual, with conflict of interest, from participating in all parts of the educational activity.

Revised the role of the individual with conflict of interest so that  the relationship is no longer   relevant to the educational activity.

   Not awarding contact hours for a portion or all of the educational activity.

 

 

 

 

  Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation.

  Undertaking review of the educational activity by a content reviewer to evaluate for potential bias,  balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.

  Other - Describe: 

 

 

 

Section 6:  Statement of Understanding

An “X” in the box below serves as the electronic signature of the individual completing this Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

 

x     Electronic Signature (Required)                         Date January 8, 2019

Diane H. Perks, DNP, CRNP

Completed By: Name and Credentials

 

 

Nurse Planner Signature (* If form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign).

An “X” in the box below serves as the electronic signature of the Nurse Planner reviewing the content of this Biographical/Conflict of Interest Form.   

 

       Electronic Signature (Required)

 

 

                         

Completed By: Name and Credentials                                                        Date

Approved Provider BIO/COI Form, 2013 criteria, 4.20.12

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