A
ANP Continuing Education PLANNER Disclosure
Name: ____________________________________________________________________________________________
Contact Phone: ______________________________________ Contact E-mail: __________________________________
SECTION I: DISCLOSURE OF FINANCIAL RELATIONSHIPS
AANP adopts the ACCME definition of commercial interest which is any entity producing, marketing, re-selling, or distributing health
care goods or services consumed by, or used on, patients. By definition, this does not include most non-profit organizations (non-
profit organizations that advocate for commercial interest are not eligible for AANP accreditation), government organizations, or
non-health care organizations. The AANP does not consider providers of clinical service directly to patients to be commercial
interests. A commercial interest is not eligible for AANP accreditation.
AANP considers financial relationships (in the preceding 12 months) to create conflicts of interest in continuing education (CE) when
individuals have both the opportunity to influence the content of a CE activity and have a financial relationship with a commercial
interest. AANP requires anyone in control of the CE content to disclose any financial relationships with commercial interest of their
own and/or their spouse/partner in the preceding 12 months.
Within 12 Months of the date of this form, have you and/or your spouse/partner had a financial relationship or other affiliation with
a commercial interest?
No (complete Section III) Yes (complete Sections II & III)
Signature ____________________________________________________________ Date: _____________________________
(Electronic signature accepted: Typed name with date indicates electronic verification of the information provided)
SECTION II: NATURE OF THE FINANCIAL RELATIONSHIPS
Please indicate the names of the organization(s) with which you and/or your spouse/partner have a financial relationship or interest,
what was received, the role, and the specific clinical areas that correspond to the relationship. Please complete all columns for each
organization. If more than five relationships, please list on separate page:
Company with which
Relationship Exists (indicate
self or spouse/partner)
What was received?
(e.g., honoraria, salary,
consulting fee, stocks or stock
options, royalty, travel, etc.)
For what role?
(e.g., Speakers’ Bureau,
employment, consultant,
advisory board, research, etc.)
For what clinical area/disease
state?
1.
1.
1.
1.
2.
2.
2.
2.
3.
3.
3.
3.
4.
4.
4.
4.
5.
5.
5.
5.
AANP Planner Disclosure_March, 2015
Page 1 of 2
SECTION III: COMPLIANCE WITH AANP ACCREDITATION POLICY
(This section MUST be completed; please initial each statement below indicating you have read, understand, and are willing to
comply)
_____ I attest that the CE content for which I am responsible will be evidence-based, fair and balanced, unbiased, and free from
commercial interest control.
_____ No promotional activities may occur during CE events. This includes distribution of product brochures or product information
in conjunction with the educational activity or handouts. No slides or handouts developed by a commercial interest may be
used during presentations. I agree to not promote any specific proprietary or commercial business interest in my role as
planner or faculty/speaker.
_____ I understand that an employee of a commercial interest may NOT serve as a faculty or planner of CE accredited by AANP if the
educational content that the employee controls relates to the products and/or services of the commercial interest employer.
If the content DOES NOT relate to the products and/or services of the commercial interest employer, the employee may be
eligible to serve as speaker or planner, but the educational content must be reviewed (should be sent with the application)
before approval of CE credit will be considered.
_____ I understand programs with faculty serving on an industry Speakers’ Bureau in related clinical areas will be considered,
providing requirements are completed and details submitted prior to the activity’s accreditation. A review of education
content materials
is required for activities covering the same clinical area as a faculty member’s Speakers Bureau activities
and the materials must be submitted with the application for approval to be considered. AANP reviewers may determine the
need for an independent peer review, which will be the responsibility of the CE planner/provider to obtain from qualified
peer reviewer (see definition of independent peer review in policy).
_____ I understand that if planners or faculty engage in a financial relationship with a proprietary entity after the CE program has
been granted AANP accreditation, but before the educational activity has been implemented/delivered, AANP must be
notified and a new disclosure form must be provided. A second review for approval will become necessary before the activity
can be delivered.
_____ I understand that if changes are made to educational presentation/material(s) after the CE program has been granted AANP
accreditation, but before the educational activity has been implemented/delivered, I must alert AANP and provide
information/documentation on the changes. A second review for approval will become necessary before the activity can be
delivered.
_____ If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine
whether a conflict of interest may exist, and I may be asked to provide additional information.
_____ I understand that failure to disclose, false disclosure, or inability to resolve conflicts of interest will require the CE Provider to
identify a replacement.
Signature: __________________________________________________________Date: ___________________________________
(Electronic Signature accepted: Typed name with date indicates electronic verification of the information provided).
AANP Planner Disclosure_March, 2015
Page 2 of 2
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome