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Conflict of Interest Form: CENTER for Nursing Excellence

COI Form- CENTER for Nursing Excellence

The potential for conflicts of interest (COI) 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. The CENTER for Nursing Excellence 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 educational activities. If the CENTER for Nursing Excellence Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role of 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. (Please reference the Content Integrity Standards for further clarity.) 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.

For questions regarding this form, please contact Kathleen Feldman at KFeldman@mednet.ucla.edu
Demographic Data
This question requires a valid email address.
Conflict of Interest Disclosure
Have you or your spouse/partner had a personal financial relationship or an actual, potential or perceived conflict of interest in the last 12 months with the manufacturer of products or services that are consumed by or used on patients? *This question is required.
Please note: This Conflict of Interest form will be kept on file at the UCLA Health CENTER for Nursing Excellence. It must be completed each calendar year to ensure that conflicts of interests and relevant financial relationships of all planners and presenters of educational activities are appropriately documented and disclosed to our learners. 
You indicated that you have a potential conflict of interest or relevant financial relationship.

Please complete the table below for all actual, potential or perceived conflicts of interest and identify the mechanisms to resolve these conflicts of interest.

*Please note all conflicts and potential conflicts of interest, must be resolved prior to the planning, implementation, and evaluation of continuing nursing education activities at UCLA Health. *This question is required.
Check all that apply Description
Consultant/Independent Contractor
Employee of Commercial Interest/Salary
Royalty Recipient
Speakers Bureau
Stock Shareholder (excluding mutual funds)
Other
Mechanisms identified to resolve conflicts of interest for this activity. (Select all that apply)
  • * This question is required.
Statement of understanding/declaration
  • I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development or presentation of educational activities.
  • I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).
  • I will inform learners when I discuss or reference unapproved or unlabeled uses of therapeutic agents or products.
Your electronic signature below serves as your attestation to the accuracy of the information provided on this Disclosure of Conflict of Interest Form.
Clear
Signature of
For questions regarding this form, please contact Kathleen Feldman at KFeldman@mednet.ucla.edu
Please note that CV/Resumes must be updated with the CENTER for Nursing Excellence every 2 years. If you have not recently submitted your CV/Resume, please send it Kathleen Feldman at KFeldman@mednet.ucla.edu as soon as possible.