Please fill out this form and return to cppn@health.ucdavis.edu.

Biographical data must be maintained for instructors/faculty and conflicts of interest must be mitigated for anyone who is involved in the planning, presentation, or implementation of a CPPN continuing education activity who have disclosed relevant financial relationship(s) with ineligible company(ies).

Must be completed prior to the activity and every 12 months for ongoing offerings.

Speaker/Presenter/Member of Planning Committee are required to complete Section 1 only

Section 1:
Title of Activity/Course: (Not the name of individual presentation) Click here to enter text.
Course Code #: Click here to enter text. (Leave blank if unknown) Education Activity Date (enter first date of course): Click here to enter a date.
Role in Educational Activity: (Click below on all boxes that apply)
☐ Speaker/Presenter ☐ Planning Committee Member ☐ Content Reviewer ☐ Other – Describe: Click here to enter text.
Name with Credentials/Degrees: Click here to enter text.
Phone Number: Click here to enter text. Email Address: Click here to enter text.
If RN, Nursing Degree(s): ☐ AD ☐ Diploma ☐ BSN ☐ Masters ☐ Doctorate
Current Employer and Position/Title: Click here to enter text.
Biographical Data: Please describe in space below your expertise and years of training specific to the educational activity listed above. Resume/CV is also acceptable and required for ACE and/or PT/PTA courses. Click here to enter text.

Conflict of Interest – All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant financial relationships** with any ineligible company* (previously termed “commercial interest”). All information disclosed must be shared with learners prior to the start of the educational activity (definitions of ineligible company* and relevant financial relationships** are below).

Yes	No	The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity. With this in mind, please answer the following:
☒	Do you have the ability to control or influence the content of an educational activity?
☐	☐	Do you have a relevant financial relationship** with an ineligible company* within the prior 24 months, the products, or services of which are pertinent to the content of the educational activity?
If answered yes to #2 above (relevant financial relationship with an ineligible company), please describe the name of the ineligible company and nature of the financial relationship: (See Definitions for Conflict of Interest) Click here to enter text.

UC Davis employees are government employees, and the state California has special conflict of interest (COI) laws and regulations affecting government employees. These laws include the Fair Political Practices Act, also known as the Political Reform Act of 1974 (PRA). In addition, federal law has special provisions relating to health care COI that result in more stringent standards than for most other businesses.

As a matter of policy, UC Davis Health prohibits its employees from engaging in any activity that places them in a COI with their official activities. Such conflicts may make it difficult for an employee to discharge his or her work duties. More information can be found on UC Davis Health Policy 1705: Conflict of Interest and the General Compliance Policies, Procedures, and References page.

*Ineligible company, previously termed “commercial interest,” as defined by ACCME and ANCC, is any company whose primary business is producing, marketing, reselling, or distributing healthcare products used by or on patients. The owners and employees of ineligible companies are considered to have unresolvable financial relationships and must be excluded from participating as planners or faculty, and must not be allowed to influence or control any aspect of the planning, delivery, or evaluation of accredited continuing education. Examples of such organizations include:

Advertising, marketing, or communication firms whose clients are ineligible companies Bio-medical startups that have begun a governmental regulatory approval process Compounding pharmacies that manufacture proprietary compounds Device manufacturers or distributors	Diagnostic labs that sell proprietary products Growers, distributors, manufacturers or sellers of medical foods and dietary supplements Manufacturers of health-related wearable products Pharmaceutical companies or distributors Pharmacy benefit managers Reagent manufacturers or sellers

An organization is eligible (NOT an ineligible company) if its mission and function are: (1) providing clinical services directly to patients; or (2) the education of healthcare professionals; or (3) serving as fiduciary to patients, the public, or population health; and other organizations that are not otherwise ineligible. Examples of such organizations include:

Ambulatory procedure centers Blood banks Diagnostic labs that do not sell proprietary products Electronic health records companies Government or military agencies Group medical practices Health law firms Health profession membership organizations Hospitals or healthcare delivery systems	Infusion centers Insurance or managed care companies Nursing homes Pharmacies that do not manufacture proprietary compounds Publishing or education companies Rehabilitation centers Schools of medicine or health science universities Software or game developers

(Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, December 2020 (www.accme.org) - ANCC’s definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition)

**Relevant financial relationships, as defined by ANCC, is when an individual has a financial relationship with an ineligible company and the educational content is related to the business lines or products of the ineligible company.

Relationships with any ineligible company may be relevant financial relationships and must be reported to and evaluated and mitigated by the CPPN Nurse Planner.

Evidence of a relevant financial relationship with an ineligible company 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 ineligible company.

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 ineligible company.

Section 2:
CPPN NURSE PLANNER to complete ☐ This is an ANCC Activity
I (Nurse Planner) have discussed with and reviewed the disclosure of the individual listed above: (Choose one) ☐ found no conflict of interest. (Proceed to Signature) ☐ mitigated their conflict(s) of interest by the following means (choose a minimum of one method and provide further explanation as needed).
Methods for mitigating Speaker, Author, Panel Member, etc. conflicts
☐ Person’s disclosed relationship(s) is not relevant to their presentation. Explain why not relevant: Click here to enter text. ☐ No changes to the content are required (content was reviewed and is balanced, objective, evidence-based, and free of bias) AND Nurse Planner and/or planning committee member will monitor educational activity to evaluate for bias in presentation. ☐ No changes to the content are required (content was reviewed and is balanced, objective, evidence-based, and free of bias) AND Nurse Planner and/or planning committee member will review participant feedback to evaluate for bias in presentation. ☐ The following changes were made to the content: Click here to enter text. ☐ Content was reviewed and I attest that it is: Valid and aligned with the interests of the public, Limited to basic science research, such as pre-clinical research and drug discovery, or the methodologies of research, and does not make care recommendations Teaches the safe and proper use of medical devices and does not recommend whether or when a device is used. ☐ Nurse Planner limited individual’s content to a presentation without diagnostic or treatment recommendations. (Document presentation)
Methods for mitigating Course Director, Planning Committee, Moderator, Content Reviewer, etc. conflicts
☐ Person’s disclosed relationship(s) is not relevant to their role in the activity (content of the activity is not related to the business lines or products of their employer/company). Explain why not relevant: Click here to enter text. ☐ I chose someone else who had no conflict of interest to control that part of the content or activity. Explain: Click here to enter text. ☐ I changed the person’s assignment so that it does not relate to their disclosed financial relationships. Explain: Click here to enter text. ☐ I changed the session or activity so that it does not relate to the products/services of an ineligible company. Explain: Click here to enter text. ☐ The content of the activity is limited to basic science research, such as pre-clinical research and drug discovery, or the methodologies of research, and they do not make care recommendations. ☐ They are participating as technicians to teach the safe and proper use of medical devices, and do not recommend whether or when a device is used. Additional Comments: Click here to enter text.

Attach disclosure information, if applicable, as provided to participants. (Publications, General Information Sheet, slide, agenda, etc.)

By affixing my name, I attest that the above information is true and accurate:

CPPN Nurse Planner: Click here to enter text.	Date: Click or tap to enter a date.	Name, Credentials