Presentation Title:

Biographical Information

CHECK ONE OR BOTH

Planner

Presenter

Biographical Data Form

Name:

(Name, Degrees and Credentials)

If RN, indicate degree(s) in nursing: [ ] Diploma, [ ] ADN, [ ] BSN, [ ] Other:

Home Address OR Business Address:

(Number and Street) (City, State, Zip)

Day Telephone:

E-Mail address:

Present Position (Title) & Employer:

Planners: Describe your familiarity with the target audience:

Presenters: Describe your expertise in this topic:

Vested Interests of Presenters

ALL PRESENTERS MUST DECLARE ANY VESTED INTERESTS ON THIS FORM

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. (If the applicant already has special forms to identify this, it does not need to be repeated on the bio form. Include the applicant’s copy of the completed forms declaring vested interest.)

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.

CHECK ONE OR BOTH

Planner

Presenter

Biographical Data Form

Name:

(Name, Degrees and Credentials)

If RN, indicate degree(s) in nursing: [ ] Diploma, [ ] ADN, [ ] BSN, [ ] Other:

Home Address OR Business Address:

(Number and Street) (City, State, Zip)

Day Telephone:

E-Mail address:

Present Position (Title) & Employer:

Planners: Describe your familiarity with the target audience:

Presenters: Describe your expertise in this topic:

Vested Interests of Presenters

ALL PRESENTERS MUST DECLARE ANY VESTED INTERESTS ON THIS FORM

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. (If the applicant already has special forms to identify this, it does not need to be repeated on the bio form. Include the applicant’s copy of the completed forms declaring vested interest.)

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.

CHECK ONE OR BOTH

Planner

Presenter

Biographical Data Form

Name:

(Name, Degrees and Credentials)

If RN, indicate degree(s) in nursing: [ ] Diploma, [ ] ADN, [ ] BSN, [ ] Other:

Home Address OR Business Address:

(Number and Street) (City, State, Zip)

Day Telephone:

E-Mail address:

Present Position (Title) & Employer:

Planners: Describe your familiarity with the target audience:

Presenters: Describe your expertise in this topic:

Vested Interests of Presenters

ALL PRESENTERS MUST DECLARE ANY VESTED INTERESTS ON THIS FORM

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. (If the applicant already has special forms to identify this, it does not need to be repeated on the bio form. Include the applicant’s copy of the completed forms declaring vested interest.)

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.

CHECK ONE OR BOTH

Planner

Presenter

Biographical Data Form

Name:

(Name, Degrees and Credentials)

If RN, indicate degree(s) in nursing: [ ] Diploma, [ ] ADN, [ ] BSN, [ ] Other:

Home Address OR Business Address:

(Number and Street) (City, State, Zip)

Day Telephone:

E-Mail address:

Present Position (Title) & Employer:

Planners: Describe your familiarity with the target audience:

Presenters: Describe your expertise in this topic:

Vested Interests of Presenters

ALL PRESENTERS MUST DECLARE ANY VESTED INTERESTS ON THIS FORM

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. (If the applicant already has special forms to identify this, it does not need to be repeated on the bio form. Include the applicant’s copy of the completed forms declaring vested interest.)

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.

CHECK ONE OR BOTH

Planner

Presenter

Biographical Data Form

Name:

(Name, Degrees and Credentials)

If RN, indicate degree(s) in nursing: [ ] Diploma, [ ] ADN, [ ] BSN, [ ] Other:

Home Address OR Business Address:

(Number and Street) (City, State, Zip)

Day Telephone:

E-Mail address:

Present Position (Title) & Employer:

Planners: Describe your familiarity with the target audience:

Presenters: Describe your expertise in this topic:

Vested Interests of Presenters

ALL PRESENTERS MUST DECLARE ANY VESTED INTERESTS ON THIS FORM

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. (If the applicant already has special forms to identify this, it does not need to be repeated on the bio form. Include the applicant’s copy of the completed forms declaring vested interest.)

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.

CHECK ONE OR BOTH

Planner

- Presenter

Biographical Data Form

Name:

(Name, Degrees and Credentials)

If RN, indicate degree(s) in nursing: [ ] Diploma, [ ] ADN, [ ] BSN, [ ] Other:

Home Address OR Business Address:

(Number and Street) (City, State, Zip)

Day Telephone:

E-Mail address:

Present Position (Title) & Employer:

Planners: Describe your familiarity with the target audience:

Presenters: Describe your expertise in this topic:

Vested Interests of Presenters

ALL PRESENTERS MUST DECLARE ANY VESTED INTERESTS ON THIS FORM

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity. (If the applicant already has special forms to identify this, it does not need to be repeated on the bio form. Include the applicant’s copy of the completed forms declaring vested interest.)

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

I have no real or perceived conflicts of interest that relate to this presentation.