Disclosure of All Financial RelationshipsChildren's Hospital Colorado is responsible for identifying relevant financial relationships between individuals in control of educational content and ineligible companies to ensure they do not introduce commercial bias into the education. Please disclose all financial relationships that you have had in the past 24 months with ineligible companies, regardless of the potential relevance of each relationship to the education and regardless of the amount. Name and Credential * First and Last Name, Credential Title of Continuing Education Program * Location of Program * Activity Date of Program * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 Role in EducationIdentify the prospective role(s) that you may have in the planning and delivery of this education. Please disclose all financial relationships that you have had in the past 24 months with ineligible companies, regardless of the potential relevance of each relationship to the education and regardless of the amount. Role in Education * Identify the prospective role(s). Planner (committee, content expert, moderator, staff involved in content development) Nurse Planner - Ensures adherence to ANCC. If RN, Provide Nursing Degree (AD, Diploma, BSN, MSN, Doctorate) Teacher, Instructor, Faculty Author, Writer Reviewer Other Role in Accredited Education Role in Education Other Role in Accredited Education Ineligible CompanyAn ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Examples of Financial RelationshipsExamples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution receives the research grant and manages the funds. Has the Relationship Ended?If the financial relationship existed during the last 24 months, but has now ended, please indicate so. This will help the education staff determine if any mitigation steps need to be taken. For specific examples of ineligible companies visit accme.org/standards. Disclosure of ALL Financial Relationships in the past 24 monthsPlease disclose all financial relationships that you have had in the past 24 months with ineligible companies, regardless of the potential relevance of each relationship to the education and regardless of the amount. In the past 24 months, I have not had any financial relationships with any ineligible companies. * No - Nothing to Report Yes - Relevant Financial Relationship to Report Ineligible Company Name * Please list the name of each Ineligible Company, Nature of Relationship, Divestment Status Nature of Financial Relationship * Please enter the Nature of each Financial Relationship. Has The Relationship Ended? * Please indicate whether the relationship has ended. Divestment status, if applicable. Ineligible Company Name 2 Please list the name of each Ineligible Company, Nature of Relationship, Divestment Status Nature of Financial Relationship 2 Please enter the Nature of each Financial Relationship. Has The Relationship Ended 2? Please indicate whether the relationship has ended. Divestment status, if applicable. Ineligible Company Name 3 Please list the name of each Ineligible Company, Nature of Relationship, Divestment Status Nature of Financial Relationship 3 Please enter the Nature of each Financial Relationship. Has The Relationship Ended 3? Please indicate whether the relationship has ended. Divestment status, if applicable. Ineligible Company Name 4 Please list the name of each Ineligible Company, Nature of Relationship, Divestment Status Nature of Financial Relationship 4 Please enter the Nature of each Financial Relationship. Has The Relationship Ended 4? Please indicate whether the relationship has ended. Divestment status, if applicable. Ineligible Company Name 5 Please list the name of each Ineligible Company, Nature of Relationship, Divestment Status. IF, reporting more than FIVE Relevant Relationships - add Ineligible Company Name, Nature, Divestment Nature of Financial Relationship 5 Please enter the Nature of each Financial Relationship. Has The Relationship Ended 5? Please indicate whether the relationship has ended. Divestment status, if applicable. Leave this field blank
