Conflict of Interest Form

Continuing Nursing Education seeks to insure balance, independence, objectivity, and scientific rigor in all its individually or jointly presented continuing education programs. All speakers participating in a continuing education program are asked to report any real or apparent conflicts of interest that may have a direct bearing on the subject matter of the program. Disclosure pertains to any financial relationship with an organization or company, e.g., pharmaceutical company, biomedical device manufacturer, or other corporation, whose products or services are related to the subject matter of the speaker's presentation. The information will be reported to conference participants either verbally or in program materials. This policy is not intended to prevent a speaker from making a presentation but merely to identify any potential conflict of interest so that listeners may form their own judgments about possible bias in the exposition of conclusions presented.

Presenter Information

Conference Title:

Conference Date:

Title of Presentation:

Presenter First Name:

Presenter Last Name:

Presenter Email Address:

Conflict Status - Please check one

I have no actual or potential conflict of interest in relation to this program.
I have a financial interest, arrangement of affiliation with one or more organizations /companies that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation, including but not limited to: consulting; a family member employed by the organization; a fiduciary responsibility; membership on a governing board; recipient of a grant or research support; a major stockholder; receiving other financial or material support (e.g., honorarium and/or travel expense reimbursement),membership on a speaker's bureau.

Conflict Disclosure
If you have indicated a conflict above, please complete the information below for all the organizations in which you are involved that might pose a conflict.

Name of Organization/Company:
Nature of Relationship:
Name of Organization/Company:
Nature of Relationship:
Name of Organization/Company:
Nature of Relationship:
Name of Organization/Company:
Nature of Relationship:
Name of Organization/Company:
Nature of Relationship:

Thank you for complying with these guidelines.

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Continuing Nursing Education · Box 359440 · Seattle, Washington 98195-9440
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The University of Washington is committed to providing access, equal opportunity and reasonable accommodation in its services, programs, activities, education and employment for individuals with disabilities. To request disability accommodation, contact the Disability Services Office at least ten days in advance of a conference at: 206-543-6450/V, 206-543-6452/TTY, 206-685-7264 (FAX), or dso@u.washington.edu.