Nurse Practitioner Education Continuum Council

Faculty / Planner Conflict of Interest Disclosure

Version 0.1 · 2026-07-20 · Complete one form per faculty or planner

Activity title

Activity date / version

Full name & credentials

Role (check all that apply)

☐ Planner☐ Faculty / SME☐ Reviewer☐ Moderator

Disclosure of relevant financial relationships

In the past 24 months, have you had a financial relationship with a commercial interest related to the content of this activity? (Examples: employment, consulting, speaking fees, ownership, research support, royalties.)

☐ No — I have nothing to disclose ☐ Yes — list below

Entity name	Nature of relationship	Content area affected

Mitigation (if yes)

Describe how conflicts will be mitigated (peer review of content, revision, recusal, alternate faculty, etc.):

Attestation

I attest that the information above is accurate to the best of my knowledge. I agree that educational content will be fair, balanced, and free of commercial bias, and that I will not promote products for personal commercial gain within the educational activity.

Signature

Date

Digital system of record (Proliforge LEARN): When faculty sign off a module in the Proliforge dashboard (SME Sign-Off + Faculty COI), the completed disclosure is stored with the course activity file and shown to learners on the module’s Disclosures page. Print this HTML form for offline use; the digital form is preferred for Proliforge-delivered activities.