2024 SHINE Conference


Disclosure of Relevant Relationships


Deadline: Sunday, February 02, 2024, at 11:59 PM EST


As someone who may be involved in the planning and/or delivery of the SHINE Conference, we would like to ask for your help in protecting our learning environment from industry influence. Please complete this disclosure form by the above date.


The information in this form is required by The Standards for Integrity and Independence in Accredited Continuing Education. If you do not complete this form, you will not be able to participate in the planning and/or delivery of this activity. For more information, view the Standards for Integrity and Independence in Accredited Continuing Education, here.


Thank you for your diligence and assistance. Please contact the Johns Hopkins Center for Nursing Inquiry at nursinginquiry@jhmi.edu or the Institute for Johns Hopkins Nursing at ijhn@jhmi.edu with any questions or concerns

Activity Information

Select the prospective role(s) you may have in the planning and delivery of the activity. Select all that apply.

If other, input your role(s).


Biographical Information

Input your first and last name.

Input your credentials. The preferred order of credentials is highest degree earned, licensure, certifications, honors. For more information, view the How to Display Your Credentials guide, here.

Input a brief biography describe your expertise related to the activity. The biography should be brief, no more than 3-4 sentences, and include a summary of your work history, professional achievements, and education.

Input your email address. If you are a Johns Hopkins employee, input your @jh.edu email address.

Input your work mailing address.

Input your work telephone number.

Select your primary employer.

Select or enter value
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If other, input the name of your primary employer.

Input your current job title.


Disclosures

Financial Relationships*

Do you have a financial relationship with any ineligible company currently or within the past 24 months? An ineligible company is defined as a company whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products or services. For specific examples of ineligible companies, view the Standards for Integrity and Independence in Accredited Continuing Education, here.

Input the name(s) of any ineligible company with which you have, or have had, a financial relationship within the past 24 months.

Select the role(s) you have, or have had, with any ineligible company within the past 24 months. Select all that apply.

If other, input the role(s).

Select the type of financial support you have received from any ineligible company, regardless of the amount. There is no minimal financial threshold. Select all that apply.

If other, input the the type of financial support received.

Healthcare Product or Service*

Do you plan to discuss a specific healthcare product or service? A healthcare product or service is defined as any product or service regulated by the Food and Drug Administration (FDA) or comparable health care regulatory agency and is intended to be used by or on patients. For specific examples of healthcare products or services, visit the FDA website, here.

Input the name(s) of the specific healthcare product or service.

Off-Label or Investigational*

Do you plan to discuss the off-label or investigational use of a drug, biological product, or medical device? Off-label or investigational use is defined as the use of a drug, biological product, or medical device for an indication, or using a dosage or dosage form, that has not been approved by the FDA. For specific examples of off-label or investigational use, visit the FDA website, here.

Input the name(s) of the drug, biological product, or medical device?

Input the off-label or investigational use(s) in question.


Attestations

Financial Relationships*

I have disclosed all relevant financial relationships with which I have, or have had, with any ineligible company within the past 24 months. I agree to disclose this information verbally and in print at the start of my presentation.

Healthcare Product or Service*

I understand my presentation must promote quality in health care and not a specific proprietary business. If I am discussing a specific healthcare product or service, I agree to use the generic name to the extent possible. If I need to use a trade name, I agree to use trade names from several companies and not just trade names from any single company.

Off-Label or Investigational*

If I am discussing any use that is off-label or investigational, I agree to disclose this information verbally and in print at the start of my presentation.

I have carefully read and considered each item on this form. I attest to the accuracy of the information given. Typing my name below serves as my electronic signature.