Instructions: This form is for faculty speakers of the PALS activities. If you participate in planning the PALS activities, please email Jeanine Hatfield at Jeanine.Hatfield@NationwideChildrens.org for the link to the planner information. If there is a perceived conflict, the nurse planner will discuss with you how the conflict will be resolved before your continued participation in this learning activity.

	Section 1: Demographic Data

	**PLEASE NOTE: Questions followed by a red *asterisk* are REQUIRED.

1.	Name, Degrees & Credentials:*

2.	If RN, nursing degree(s):
	AD    Diploma    BSN    Masters    Doctorate

3.	Home Address OR Business Address*
	Address Line 1   Address Line 2   City   State   Zip

4.	Day Telephone (XXX-XXX-XXXX):*

5.	Email Address:*

6.	Present Position (Title) & Employer:*

	Section 3: Faculty/Content Expert Information

7.	Describe your expertise in this topic:*

If you are in a position to control the content of this educational activity (planner, faculty presenter, content specialist), you must disclose whether or not you have a conflict of interest. Conflict of interest disclosure identified the presence or absence of any potentially biasing relationship of a financial, professional or personal nature. A perceived conflict of interest would occur, for example, if you have or a member of your family has, within the past 12 months, received a salary, royalty, speaking honorarium, research appointment, board of directors remuneration, or consulting fee from an organization whose product or service is being discussed in the learning activity or if you or a family member own stock in such a company. Conflict of interest would also occur if you have any potential to benefit personally or professionally from the presentation (work for a proprietary company presenting the learning activity, have written a book about the topic, provide consulting services related to the topic, etc.) All information disclosed must be shared with the audience on the program handouts, advertising and/or audiovisual presentation.

	Section 4: Conflict of Interest

8.	Is there a perceived financial, professional or personal conflict of interest (self or family)?*
	No If yes, describe the perceived conflict:

	Section 5: Resolution of Conflict

9.	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.    I have discussed this conflict of interest with the nurse planner and agree to the provider unit's policy.    I have signed a statement that says I will present information fairly & without bias.    In conjunction with 1 & 2, I understand that the nurse planner or designee will monitor session to ensure conflict does not arrise.    Other: Describe:

	Section 6: Off-label Use

10.	Presenter/Content Specialist discussion of off-label uses:*
	Yes No

11.	If yes, you must disclose this information during your presentation. How will you do this?
	Information provided on handouts    Information provided in audiovisuals (slides, overhead, powerpoint, etc.)    Other: Describe:

	Section 7: Signature

12.	By entering your name, you are providing your electronic signature approving all the information entered above. *

	Ohio Nurses Association 2009 Criteria