OHIO LACTATION CONSULTANT ASSOCIATION (OLCA)
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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


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

    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.

    Part III

    OHIO LEAGUE FOR NURSING, PLAN FOR SINGLE CE ACTIVITY

    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.


    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

    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.
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  • Home
  • COVID-19 and Breastfeeding
  • About Us
    • Our Mission
    • Who We Are
    • Regional News >
      • Southwest News
    • Learn About OLCA Positions
  • Education and Breastfest
    • Meetings
    • Breastfest Conference >
      • Breastfest 2021
      • Awards, Grants, and Scholarships
    • Webinars
    • CERP verification
  • Membership
    • Become a Member
    • Members Only >
      • OLCA Member Meeting Minutes
      • ILCA Recordings >
        • ILCA Recordings - 2019
        • ILCA Recordings - 2018
        • ILCA Recordings - 2017
        • ILCA Recordings - 2016
        • ILCA Recordings - 2015
      • The Legal Stuff
  • Resources
    • How Do I Become a Lactation Consultant?
    • Find an IBCLC
    • For new IBCLCs
    • Insurance Coverage Resources
    • OLCA Library
  • Advocacy and Equity
  • Newsletter
  • Playing Page