VUMC ANCC Provider Unit Financial Disclosure Screening

As an accredited provider, we require your assistance to comply with accreditation guidelines and help us create high-quality accredited continuing education that is independent of industry influence. To participate in this educational activity, all individuals who have the ability to influence and/or control the content of this activity must disclose all financial relationships, within the last 24 months, with all companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

For more information, please refer to the Standards for Integrity and Independence in Accredited Continuing Education

First Name

Last Name

Full credentials

Please include all credentials: degrees, licensure, and certifications: e.g., MSN, RN, NPD-BC)

Email Address

Phone Number

Please provide the best phone number to reach you directly. This phone number will only be used if/when mitigation is required for a relevant financial relationship(s) described below.

Phone

Financial Relationships

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (definition: 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 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 MUST be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies MUST be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds.

For each financial relationship enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

For specific examples of ineligible companies visit www.accme.org/standards

In the past 24 months, have you had a financial relationship with an ineligible company (defined above)?

If unsure, select yes and complete the remaining questions.

Yes

Send me a copy of my responses

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