Hospital & Clinics
UAMS Office of Continuing Education
Office of Continuing Education
Frequently Asked Questions
Calendar of Events
Conferences and Workshops
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Applying for Accreditation
Regularly Scheduled Series
MOC Part IV
MOCA Simulation Course
Applying for Accreditation
Nurse Planner Application and COI Form
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Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Credentials / Degrees
If RN, Nursing Degrees:
RN License Number
Position / Title
Upload CV / Resume
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
,* the products or services of which are pertinent to the content of the educational activity.
, as defined by ACCME, ANCC and ACPE, 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 (excepting non-profits, government organizations or providers of clinical services directly to patients).
All individuals who have the ability to control or influence the content of an educational activity must disclose all
** 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.
, as defined by ANCC, ACPE and ACCME 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.
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 immediate family member or domestic partner?
If a conflict of interest exists, you will be contacted by the course planners to determine how to resolve the conflict.
Nature of Conflict of Interest
If you have a SALARY conflict of interest, please indicate the name of the company(s) and your role for each company.
If you have a ROYALTY conflict of interest, please indicate the name of the company(s) and your role for each company.
If you have a STOCK conflict of interest, please indicate the name of the company(s) and your role for each company.
If you have a SPEAKERS BUREAU conflict of interest, please indicate the name of the company(s) and your role for each company.
If you have a CONSULTANT conflict of interest, please indicate the name of the company(s) and your role for each company.
If you have a GRANTS RESEARCH conflict of interest, please indicate the name of the company(s) and your role for each company.
If you have a PROPERTY RIGHTS conflict of interest, please indicate the name of the company(s) and your role for each company.
Treatment Recommendations and Research Citations
: If you make treatment recommendations or reference scientific research as part of your presentation, please note that all studies and evidence must be referenced on presentation slides or handouts.
By typing your name or uploading your electronic signature below, you are attesting that all clinical recommendations are based on evidence that is accepted within the profession of medicine and all scientific research referred to, reported, or used in support of or justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection, and analysis.
You are also attesting to the accuracy of the information submitted in this Biographical & Conflict of Interest Form.
Name and Credentials
First, last, and credentials