Speaker Forms

Please complete all 4 parts of this form!

Ohio League for Nursing: BIOGRAPHICAL DATA FORM

Complete this form for each member of the planning committee and each faculty presenter. An individual may be both on the planning committee and be a faculty presenter.

Part I

Please select all the apply: *

RN providing direction Planning committee Faculty

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Credentials *

Email *

Current Position *

Place of Employment *

Brief Description *

Education (list each credential, where obtained, and major area of study):

Credential *

Where Obtained (school name) *

Area of Study *

Credential *

Where Obtained (school name) *

Area of Study *

Credential *

Where Obtained (school name) *

Area of Study *

If faculty, please describe your expertise on this topic. *

Part II

Conflict of Interest Statement Faculty, Planner

Conflict of interest is defined as having a significant financial interest in a product to be discussed; or is or has been an employee of a company with such financial interest that is providing or supporting this program. Conflict of interest does not prevent a speaker from making a presentation, but the audience must be informed of this relationship at the start of the activity.

Choose One *

I have no real or perceived conflicts of interest that relate to this presentation. I have the following or perceived conflicts of interest that relate to this presentation.

Conflict of interest has been resolved by (Please enter "N/A" if there is no conflict of interest to disclose): *

Signed *

Date *

Part III

OHIO LEAGUE FOR NURSING, PLAN FOR SINGLE CE ACTIVITY

Name of Program: *

Behavioral Outcomes: One outcome per hour. Must start with a measurable behavior. Use one space for objective.
Content Outline: Content must relate to each outcome and not be a restatement of the outcome. Include enough detail so the reviewers will know what will be presented.
Time Frame: Show time in minutes for each objective
Faculty: Indicate faculty for each objective
Teaching Methods: Describe method(s) for each outcome.

Behavioral Outcome I: *

Content Outline I: *

Time Frame I: *

Faculty I: *

Teaching Methods I: *

Behavioral Outcome II: *

Content Outline II: *

Time Frame II: *

Faculty II: *

Teaching Methods II: *

Behavioral Outcome III: *

Content Outline III: *

Time Frame III: *

Faculty III: *

Teaching Methods III: *

Part IV

INTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS

Speakers whose presentations are evaluated for Continuing Education Recognition Points (CERPs) from IBLCE must complete the Speaker Disclosure / Conflict of Interest Declaration. Any relevant information provided on the Declaration will be disclosed to the program audience in written conference materials. Failure to provide a Speaker Disclosure / Conflict of Interest Declaration may result in denial of CERP credit from IBLCE.

It is the policy of the IBLCE to make best efforts to ensure balance, independence, objectivity, and scientific rigor in all programs that qualify for IBLCE Continuing Education Recognition Points (CERPs).
Consequently, all persons participating in any program for which IBLCE CERPs are awarded are expected to disclose to the program audience any real or apparent affiliations that may have a bearing on the subject matter of their presentation.
Such affiliations include, but are not limited to:

manufacturers or marketers of infant artificial feeding products;
pharmaceutical companies;
manufacturers or marketers of biomedical devices, including any devices intended to be used during breastfeeding/lactation; and
any other persons or entities related to the subject matter of the presentation topic or the general topic of the program as a whole.

The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any potential conflict of interest shall be identified openly so that listeners may form their own judgments about the presentation with the full disclosure of pertinent facts. It remains for the audience to determine whether the speaker’s outside interests may reflect a possible bias in either the exposition or the conclusions presented.

CERP Program Sponsor: Ohio Lactation Consultant Association (OLCA)

Program Provider’s Address 6077 Far Hills Ave. PMB #288, Centerville, Ohio 45459-1923

CERP Program Title: Breastfest 2021: Virtually Together: Lactation Support in a New Reality

CERP Program Date: March 19-20, 2021

CERP Program Location: Virtual

SPEAKER: Please complete all applicable sections on this disclosure form.

DECLARATION

Choose One *

I have no actual or potential declarations to make in relation to this program. I have an affiliation with one or more persons or entities that could be perceived as having a bearing on my presentation of this subject.

List ALL current affiliations and name of organizations below: *

Date *

Signature *

Possible Types of Affiliations include: Grant/Research Support; receipt of Honoraria, Travel, or other Benefits; acting as a Consultant / Independent Contractor, Employee, Officer or Director, or Owning a Self-Managed Equity Interest; participation as part of a Speaker’s Bureau or being a Regular Contributor to a Publication; having a Close Friend or Family Member who is an Officer, Director, Employee, or who has a Self-Managed Equity Interest; and any other Financial or Material Support.

Bibliography - Paste here *

Submit

Please complete all 4 parts of this form!

Ohio League for Nursing: BIOGRAPHICAL DATA FORM

Part I

Part II

Conflict of Interest Statement Faculty, Planner​

Part III

OHIO LEAGUE FOR NURSING, PLAN FOR SINGLE CE ACTIVITY

Part IV

INTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS

SPEAKER: Please complete all applicable sections on this disclosure form.

DECLARATION

Conflict of Interest Statement Faculty, Planner