R. Commercial Support (if applicable) page 13] [see “Guidelines” – Does this activity receive any commercial support? Yes No If to Section S. “no”, proceed If Support “yes”, attach “Commercial Agreement(s)” Pages S. Disclosures Provided to Activity Participants Methods page 14] – [see “Guidelines” – Disclosures Promotional Handout AV Slide Material 1. Requirements for Successful Completion 2. Absence or Presence of Conflicts of Interest Disclosures required if applicable: Yes Yes Yes 3. Commercial Support N/A N/A N/A Yes Yes Yes 4. Joint Provider Statement N/A N/A N/A Yes Yes Yes 5. Expiration Date for Awarding Contact N/A For N/A For PD N/A For PD Hours(Enduring Materials Only) PD activity activity activity A COPY OF THE DOCUMENTATION OF THE WRITTEN DISCLOSURE(S) THAT ADDRESSES ALL OF THE ABOVE COMPONENTS MUST BE INCLUDED WITH THIS TOOL. (if applicable) T. Joint Providership page 15] [see “Guidelines” – Will the activity be joint provided? Yes No If yes, complete the following grid: Name of joint providing organization(s) Joint Provider agreement Page # Summative Evaluation: 1. ___________Nurse Planner initials (required): Upon completion of the activity, a summative evaluation will be generated and kept on file for six (6) years.
R. Commercial Support (if applicable) [see “Guidelines” – page 13] Does this activity receive any commercial support? Yes No If “no”, proceed to Section S. If “yes”, attach “Commercial Support Agreement(s)” Pages S. Disclosures Provided to Activity Participants – Methods [see “Guidelines” – page 14] Disclosures Promotional Material Handout AV Slide 1. Requirements for Successful Completion 2. Absence or Presence of Conflicts of Interest Disclosures required if applicable: 3. Commercial Support Yes N/A Yes N/A Yes N/A 4. Joint Provider Statement Yes N/A Yes N/A Yes N/A 5. Expiration Date for Awarding Contact Hours(Enduring Materials Only) Yes N/A For PD activity Yes N/A For PD activity Yes N/A For PD activity A COPY OF THE DOCUMENTATION OF THE WRITTEN DISCLOSURE(S) THAT ADDRESSES ALL OF THE ABOVE COMPONENTS MUST BE INCLUDED WITH THIS TOOL. T. Joint Providership (if applicable) [see “Guidelines” – page 15] Will the activity be joint provided? Yes No If yes, complete the following grid: Name of joint providing organization(s) Joint Provider agreement Page # Summative Evaluation: 1. ___________Nurse Planner initials (required): Upon completion of the activity, a summative evaluation will be generated and kept on file for six (6) years.