Disclosure of All Financial Relationships
Children'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.
First and Last Name, Credential
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Identify the prospective role(s) that this person may have in the planning and delivery of this education. 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 (please identify)
Ineligible Company
An 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 Relationships
Examples 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.
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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. In the past 24 months, I have not had any financial relationships with any ineligible companies.
Please list the name of each Ineligible Company in numerical order. Ex. 1. Pfizer 2. Merck 3. Sanofi
Please enter the Nature of each Financial Relationship as numbered above. e.g. 1. Consultant 2. Advisor 3. Principal Investigator
Please indicate whether the relationship has ended. Divestment status, if applicable. 1. Divested