Office of Professional & Community Engagement
1305 N. Martin | PO Box
210203 | Tucson, AZ 85721
520.626.6151 | cne@uanursing.arizona.edu
Content Integrity Form
Please enter the email address of the person completing this form in the field below. If you wish to save and complete the form at a later time you will be prompted to confirm or add an email address - be sure it is the one entered below.
EMAIL
Title of Activity
Date form completed
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Month
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Day
Year
Date
Activity Type
Provider-directed and provider paced (Live)
Provider-directed and learner paced (Enduring)
If live , date of activity
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Month
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Day
Year
Date
If enduring , start date
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Month
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Day
Year
Date
If enduring , expiration
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Month
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Day
Year
Date
Nurse Planner
The Nurse Planner must be a currently licensed registered nurse with a baccalaureate degree or higher in nursing, and be actively involved in planning, implementing and evaluating this continuing education activity.
Name of Nurse Planner
Nurse Planner Credentials
Email
Phone 1
Phone 2
Mailing Address
Content integrity
maintained by: (Check all that apply)
Integrity
The commercial support/sponsorship policy/procedure has been discussed with those providing commercial support or sponsorship.
The commercial support/sponsorship policy/procedure has been shared in writing with those providing commercial support/sponsorship.
Faculty/Presenters/Authors have been informed of the policy/procedure re: commercial support and/or sponsorship and agree to not promote the products or entity providing the financial or in-kind support.
In conjunction with above, the session will be monitored and violators of policy will not be asked to present again.
Other
Bias:
Precautions to prevent bias in the educational content: (Check all that apply).
Bias
Commercial support/sponsorship and bias has been discussed with each presenter.
Each Faculty/Presenter/Author has signed a statement that says s/he will present information fairly and without bias.
In conjunction with the above, the session will be monitored and violators of policy will not be asked to present again.
Other
Signed commercial support or sponsor agreement
attached and includes:
Statement that the provider of commercial support or sponsorship may not participate in any component of the planning process of an educational activity.
Statement of understanding that the commercial support or sponsorship will be disclosed to the participants of the educational activity
Statement of understanding that the provider of commercial support or sponsorship must agree to abide by the provider’s policies/procedures
Amount of commercial support or sponsorship and description of in-kind donation
Name and signature of the individual who is legally authorized to enter into contracts on behalf of the provider of commercial support or sponsorship
Name and signature of the individual who is legally authorized to enter into contracts on behalf of the provider of the educational activity
Date the agreement was signed
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Last updated March 2014
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