Yes (please list relationship and company name) Signature of Person Disclosing: ____________________________________Date: _ _____________ (Typing in your name acts as your signature) FDA Approved Drug and Devices Assurance Statement University Health Systems is required by the TNA and ANCC COA guidelines to instruct you that any discussions regarding the utilization of FDA approved drugs or devices must be within approved regulations. If you discuss the utilization of FDA drugs or devices that are outside approved regulations (off-label or investigational uses), you must clearly delineate this for your audience. Signature of Person Disclosing: ____________________________________Date: _ _____________ (Typing in your name acts as your signature) OFFICE USE ONLY: For University Health System Planner use only: Resolution of potential conflicts: No relevant relationship(s) to resolve Session will be monitored to ensure □ □ conflict does not arise The conflict was discussed with the individual Provided talking points/outline □ □ Restricted presentation to clinical data Data, slides added or removed □ □ Reassigned faculty’s lecture/topic Reviewed content free of □ □ – sponsorship/commercial bias _______________________________________________________________________ Signature of Nurse Planner: ______________________________________ Date: ______________ Abstract Instructions To be eligible, abstracts must include required subheadings specific to each institute; see below.
Yes (please list relationship and company name) Signature of Person Disclosing: ____________________________________Date: _ _____________ (Typing in your name acts as your signature) FDA Approved Drug and Devices Assurance Statement University Health Systems is required by the TNA and ANCC COA guidelines to instruct you that any discussions regarding the utilization of FDA approved drugs or devices must be within approved regulations. If you discuss the utilization of FDA drugs or devices that are outside approved regulations (off-label or investigational uses), you must clearly delineate this for your audience. Signature of Person Disclosing: ____________________________________Date: _ _____________ (Typing in your name acts as your signature) OFFICE USE ONLY: For University Health System Planner use only: Resolution of potential conflicts: □ No relevant relationship(s) to resolve □ Session will be monitored to ensure conflict does not arise □ The conflict was discussed with the individual □ Provided talking points/outline □ Restricted presentation to clinical data □ Data, slides added or removed □ Reassigned faculty’s lecture/topic □ Reviewed content – free of sponsorship/commercial bias _______________________________________________________________________ Signature of Nurse Planner: ______________________________________ Date: ______________ Abstract Instructions To be eligible, abstracts must include required subheadings specific to each institute; see below.
2012%20Abstract%20Packet.docx