Biographical and COI Form for CME Faculty

Biographical & Conflict of Interest Form (Activity Checklist)

Step 1 of 3

  • Please list your administrative assistant's name and contact information (if applicable)

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  • Please upload your most current CV/resume
    *Off-label use is the practice of prescribing pharmaceuticals or devices for an unapproved indication or in an unapproved age group, unapproved dose or unapproved form of administration.
    Select all that apply.
  • If the target audience is not listed above, please list your target audience.
  • Nursing accreditation requires that you provide scholarly references. Professional association websites, or generally applicable articles are fine. List DOES NOT have to be all-inclusive of everything consulted for your talk.
  • If you prefer, you may upload a file with your references.

  • Please list 3-5 objectives per credit hour of presentation.

    Remember learning objectives must be consistent with the above activity type and must be measurable. If your target audience includes both pharmacists and technicians, you must write separate objectives for both audiences that apply to their scope of practice.

    (*Verbs to AVOID while writing objectives: appreciate, enjoy, really understand, be acquainted with, fully appreciate, realize, be aware of, grasp the significance of, remember, be familiar with, sympathize with, believe, know, understand, comprehend, learn)

  • Please list 2-3 learning objectives for your presentation.
  • Give a general overview of the topics (key points) your presentation will address. These should be more extensive than your objectives, and can be simply a list of concepts rather than complete statements.
  • (If the description of expertise does not provide adequate information, the Nurse Planner may request additional documentation.)