Required Forms Checklist:

Transcription

1 Proposal Submission Please use this cover letter for all submissions. Title of Workshop: Submitted by: (Main Contact Name) Organization: Mailing Address : Phone: Type Abstract Here: Objective and Content Grid Required Forms Checklist: Biographical Data COI Form (for EACH presenter); Please complete Sections 1, 3, 4 and 5 Disclosure of Relevant Financial Relationships (for EACH presenter) **Does the Disclosure of Relevant Financial Relationships have an original signature? (MANDATORY) Supporting Study or Journal Article (Please cite here if available electronically) All proposals (one original plus one additional copy) must be received by Monday, October 19, 2015 by 4:00PM. All forms and submitted materials must be typed and not handwritten. Please do not staple documents. Call for Workshops forms are also available at

2 Objective and Content Grid (Duplicate form for additional objectives and content) Educational Activity Title: Hospice & Palliative Care the Original Triple Aim HPCANYS 36 th Annual Interdisciplinary Seminar & Meeting Workshop Title: Objectives Content Time List objectives in language that indicates measurable/learner oriented outcomes. (e.g. the learner will be able to:) One action verb per objective. One-two objectives per hour of teaching is sufficient. List each topic to be covered and provide an outline of the content to be presented for each objective. Content must be more than a restatement of the objective. Must contain sufficient detail to insure learning objective will be met. Frame State the time frame for each objective. Content expert(s) List the presenter(s)/ content expert(s) for each objective. Teaching Strategies Describe the teaching strategies for each objective.

3 Northeast Multistate Division (NE MSD) Biographical and Conflict of Interest Form Title of Educational Activity: HPCANYS 36th Annual Interdisciplinary Seminar & Meeting Education Activity Date: 4/1/2016 Role in Educational Activity: Content Expert Nurse Planner X Faculty/Presenter/Author Content Reviewer Other Describe: Section 1: Demographic Data Name with Credentials/Degrees: If RN, Nursing Degree(s): Diploma AD BSN Masters Doctorate Address: Phone Number: Address: Current Employer and Position/Title: Retired Section 2: Expertise - Planning Committee (Presenters: DO NOT Complete This Section) If a planning committee member, select area of expertise specific to the educational activity listed above: Nurse Planner Content Expert Other *If other explain: Please describe expertise and years of experience specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the Accredited Approver may request additional documentation.) Section 3: Expertise - Presenter/Faculty/Author/Content Reviewer An "X" on this line identifies the expertise information the same as listed above. Please describe expertise and years of experience specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the Accredited Approver may request additional documentation.) Northeast Multi-State Division (NE-MSD) Individual Activity Bio Data-Conflict of Interest Form Dec 2014 Page 1 of 4

4 Section 4: Conflict of Interest The potential for conflicts of interest 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 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 an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as 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. Commercial Interest Organizations are ineligible for accreditation. An organization is NOT a Commercial Interest Organization* if it is: A government entity; A non-profit (503(c)) organization; A provider of clinical services directly to patients, including but not limited to hospitals, health care agencies and independent health care practitioners; An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to providers or developers of electronic health information systems, database systems, and quality improvement systems; A non-healthcare related entity whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on patients. Liability insurance providers Health insurance providers Group medical practices Acute care hospitals (for profit and not for profit) Rehabilitation centers (for profit and not for profit) Nursing homes (for profit and not for profit) Blood banks Diagnostic laboratories (*Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 ( - 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) 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. Northeast Multi-State Division (NE-MSD) Individual Activity Bio Data-Conflict of Interest Form Dec 2014 Page 2 of 4

5 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. Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner? Yes No If yes, complete the table below for all actual, potential or perceived conflicts of interest**: Check all that apply Category Description Salary Royalty Stock Speakers Bureau Consultant Other ** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity. Section 5: Statement of Understanding Completion of the line 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. Typed or Electronic Signature: Name and Credentials (Required) Date: Section 6: Conflict Resolution (to be completed by Nurse Planner) (Presenters: DO NOT Complete This Section) Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply) Not applicable since no conflict of interest. Removed individual with conflict of interest from participating in all parts of the educational activity. Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the educational activity. Not awarding contact hours for a portion or all of the educational activity. Northeast Multi-State Division (NE-MSD) Individual Activity Bio Data-Conflict of Interest Form Dec 2014 Page 3 of 4

6 Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity. Other - Describe: (Presenters: DO NOT Complete This Section) Nurse Planner Signature (* If form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign the form). Completion of the line below serves as the electronic signature of the Nurse Planner reviewing the content of this Biographical/Conflict of Interest Form Electronic Signature: Name and Credentials (Required) Date: Northeast Multi-State Division (NE-MSD) Individual Activity Bio Data-Conflict of Interest Form Dec 2014 Page 4 of 4

7 Name: Disclosure of Relevant Financial Relationships Activity: HPCANYS th Annual Interdisciplinary Seminar & Meeting Date of Activity: April 1, 2016 First, list the names of proprietary entities producing health care goods or services, consumed by, or used on, patients, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours. Second, describe what you or your spouse/partner received (ex: salary, honorarium etc). Albany Medical College does NOT want to know how much you received. Third, describe your role. Commercial Interest Nature of Relevant Financial Relationship (Include all those that apply) What was received For What Role? Example: Company X Honorarium Speaker I do not have any relevant financial relationships with any commercial interests. Signature What was received: 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. Example terminology Date Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities (please specify). Glossary of Terms Commercial Interest The ACCME defines a commercial interest as any proprietary entity producing health care goods or services, used on, or consumed by, patients, with the exemption of non-profit or government organizations and non-health care related companies. Financial relationships Financial relationships are 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. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. Relevant financial relationships ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines relevant financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. Conflict of Interest Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship. ACCME Form to Identify Relevant Financial Relationships Page 1 of 1 328_

8 Name: Disclosure of Relevant Financial Relationships Activity: HPCANYS'016 36th Annual Interdisciplinary Seminar & Meeting Date of Activity: April 1, 2016 First, list the names of proprietary entities producing health care goods or services, consumed by, or used on, patients, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours. Second, describe what you or your spouse/partner received (ex: salary, honorarium etc). Albany Medical College does NOT want to know how much you received. Third, describe your role. X'ature of Relevant Financial Relationship (Include all those that apply) Commercial Interest What was received For What RoleV Example: Company Honorer/um Speaker I do not have any relevant financial relationships with any commercial interests, Signature Jane Kramer Example terminology Date 10/19/15 What wss received: Salary, royalty, inlefisctusl property Role(sh Employmenl, management position, independent rights, consulting fee, honoraria, ownership interest (e,g contractor (induding contracted research), consulting, stocks, stock options or other ownership interest, exduding speaking snd teaching, membership on advisory diversified mulusl funds), or other financial benefit. committees or review panels, board membership, and 'other activities (plesse specify). Glossary of Terms Commsrclsl Interest The ACCME defines s "commercial interest as any propriststy entity producing health care goods or services, used on, or consumed by, patients, vdith the exemption of non-profit or government organizations and non-heslth care related companies. Financial relationships Financial relationships srs 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 finsncisl benefit. Financial benefits are usually associated vfilh roles such as employmonl, management position, independent contractor (mcluding contracted research), consulting, speaking snd teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of Ihe person involved ln the CME activity to include financial relationships of s spouse or partner, Relevant financial relationships ACCME focuses on flnsndsl relationships vfiilh commercial interests in the 12-month period preceding the time that Ihs individual is being asked to assume a role controlling content of the CME activity. ACCME hss not sst s minimal dollar amount for relagonships to be significant. Inherent in any amount is ihs incentive to maintain or increase the value of the relationship. The ACCME defines "'relevant'inancial rslsfionships as financial relationships in any amount occurring within the psst 12 months that create a conflict of interest, Conflict of Interest Circuusls nces creole a confiict of interest vthsn on iud Mdusl hss an opportunity to sffsd C ME content about products or soivkes of s commercial interest vfith which hs/sho hss s finsndsl rolslionship, ACCME/5/ Foun to Identify Relevant Financial Relationships Page 1 of