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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. 

Conference Title:________________________________________________________________
Conference Date:_________________________________________________________________   
Title of Presentation:_______________________________________________________________
Name of Presenter:_______________________________________________________________





__I have no actual or potential conflict of interest in relation to this program.


Date:_________________





__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.


Date:_________________





If you have indicated a conflict, 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.
Please mail or FAX this form to:

University of Washington
Continuing Nursing Education
Box 359440
Seattle, WA 98195-9440
Phone: (206) 543-1047
Fax: (206) 543-6953


Contact cne@u.washington with your questions or comments about this site.
© University of Washington, Seattle, Washington, USA
Revised - Sept 2008

www.uwcne.org/stationery/conmai.htm



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