Educator BioData Form

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DIRECTIONS: Please complete all fields and submit form. This form is required for all Instructors & Facilitators teaching for the Center for Innovative Learning.

Date Completed *

MM/DD/YYYY

Demographic Data

Last Name *

First Name *

Middle Name or Middle Initial *

Name and Credentials as you would like listed on the evaluation form: *

*Credentials must be listed with the highest degree first

Degrees *

Certifications *

Member / Affiliate of Professional Organizations *

i.e. NCNA, AORN

Day Telephone *

Email Address *

Present Position (Title) *

i.e. Clinical Nurse Specialist

Employer *

i.e. WakeMed Health & Hospitals

Describe your familiarity/expertise with one or more of the following:

I represent the target audience by: *

Please Describe.

I have content expertise in this topic by: *

Please Describe:

Other

Please Describe

Conflict of Interest Statement

As a planner, presenter, and/or content specialist, you must disclose whether or not you have a conflict of interest. Conflict of interest disclosure identifies the presence or absence of any potentially biasing relationship of a financial, professional or personal nature. If there is a perceived conflict, the nurse planner will discuss with you how the conflict will be resolved before your continued participation in this learning activity.

Conflict of Interest *

Is there a perceived financial, professional or personal conflict of interest (self or family)?

Yes

If yes, please describe the perceived conflict of interest

Off label Use (unapproved or investigational usage of medication or devices) *

As a Presenter/Content Specialist, will there be discussion of off-labeled uses?

Yes

Not applicable (because I am not the presenter/content specialist)

If yes, please describe the off-labeled uses

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