2021 Pharmacology CE Agreement & Disclosure – Institute for NP Excellence

Welcome to your 2021 Pharmacology CE Agreement & Disclosure

Please read and mark to accept each of the following statements. The form must be submitted no later than August 15, 2021. To complete the form, type your name and date into the final spaces.

Please read and mark to accept each of the following statements. The form must be submitted no later than September 1, 2018. To complete the form, type your name and date into the final spaces.

I do not have any financial relationships with commercial companies relevant to the proposed presentation

I will make meaningful disclosure to the attendees if products or procedures I discuss are off- label, unlabeled, experimental, and/or investigational (not FDA approved), and any limitations on the information that I present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.

Any selection of subject matter for this activity will be done to improve the quality of healthcare. To the best of my ability, I will not let any personal financial relationships influence this selection process. All content will be free of commercial bias. No product, service, or therapeutic option will be over-represented when comparing competing products, services, and therapeutic options. Generic names will be used whenever possible. If appropriate, trade names from several companies will be used.

I have not and will not accept an honorarium, additional payment, or reimbursements except for the waived registration and any other offers included in my invitation letter from the INPE or Augusta UAPRN for my participation in this activity.

All clinical recommendations that I make for patient care as part of my content will be based on the best available evidence. To the extent practical, recommendations involving clinical practice in this activity will be substantiated by peer-reviewed sources. I understand that my CE activity presentation/materials may be prospectively peer-reviewed for fair balance and validation of content and may require editing.

I understand the need to submit brief biosketch to [email protected] for registration material and accreditation and to request any unique AV needs beyond those provided by September 8, 2018

I will submit an editable set of presentation slides to [email protected] by October 7, 2018

I will submit at least 3 learning objectives and 3 references for the session by September 22, 2018

Thank you for completing this agreement/disclosure form. If you were unable to accept any of the requirements, please contact [email protected] as soon as possible.