2016 Fall Conference Speaker Forms


Society of Gastroenterology Nurses and Associates


PART 1 - Biographical Data and Conflict of Interest Form

Title of Presentation (*)

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Your Name (with degrees & credentials) (*)

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If you are an RN, what are your degrees?

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Address (*)

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City (*)

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State (*)

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Zip Code (*)

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Email Address (*)

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Present Position (title) (*)

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Employer Name (*)

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Employer City (*)

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Employer State (*)

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Please describe expertise and years of training specific to the topic being presented on in the educational activity listed above (e.g., education, work experience, honors, professional publications) Note that if the description of expertise does not provide adequate information, the SGNA Approver Unit may request additional documentation. (*)

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CONFLICT OF INTEREST


Each individual who is in a position to control the content of a continuing education activity must disclose all relevant relationships with any entity in a position to benefit financially from the success of this CE activity. Examples of relevant relationships include (but are not limited to) those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit related to this particular CNE activity.


Relevant relationships can also include ‘contracted research’ where the institution receives a grant and manages the grant funds and the individual is the principal or a named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking, teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. ANCC considers relationships of the individual involved in this continuing nursing education activity to include financial relationships of the individual’s spouse/partner.


ANCC considers relationships occurring within the 12 months prior to the implementation date of this activity as “relevant” to conflict of interest. When a person separates from such a relationship, it ceases to be a conflict of interest but it must be disclosed to the learners for 12 months after the termination of the relationship.


All information disclosed must be shared with the participants/learners on program handouts, advertising and/or audiovisual presentation.

Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner related to this CNE activity? (*)



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STATEMENT OF UNDERSTANDING


An “X” in the box below serves as the electronic signature of the individual completing this Biographical/Conflict of Interest Form and attests to the accuracy of the information given above. The individual completing the form is the planner/presenter whose name is listed at the top of the form.

Electronic Signature (Required) (*)

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Print Name and Credentials (*)

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PART 2 - Objectives and Content of Educational Activity

List Objectives - must be measurable, singular, and learner focused. [Ex: List the indications for colonoscopy.] (*)

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List Content - should be listed and not merely a restatement of the objective. It should be directly related to the corresponding objective. Ex: a) Lower GI bleeding, b) evaluation of abnormalities found on radiographic exam, c) screening in patients with a personal history of polyps or colorectal cancer (*)

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List time allotted. Ex: 50 minutes for Presenter; 10 minutes Q&A (*)

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If using multiple presenters, list which presenter will cover each objective. Ex: Christopher A. Kelsey, MD Teaching Strategies

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List all strategies utilized. Ex: Slide presentation, lecture, case study (*)

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