Please fill out the following application in accordance with ANCC and IBLCE guidelines.
Along with a few demographic questions, you will be asked to submit a short biography (1-2 paragraphs), photo, and Curriculum Vitae prior to submitting the application.
In ongoing efforts to improve educational opportunities, presenters are asked to acknowledge commitments made between the presenter and USLCA. Please read through each statement carefully so as to indicate agreement.
Additionally, presenters are asked to disclose: (1) all conflicts of interest, and (2) any affiliations that may have bearing on the presentation.
* Required fields. May not be left blank.
If RN, check highest degree earned.
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua & Barbuda
Bosnia & Herzegovina
British Indian Ocean Territory
British Virgin Islands
Central African Republic
Cocos (Keeling) Islands
Congo - Brazzaville
Congo - Kinshasa
French Southern Territories
Heard & McDonald Islands
Hong Kong SAR China
Isle of Man
Macau SAR China
Northern Mariana Islands
Papua New Guinea
São Tomé & Príncipe
South Georgia & South Sandwich Islands
St. Kitts & Nevis
St. Pierre & Miquelon
St. Vincent & Grenadines
Svalbard & Jan Mayen
Trinidad & Tobago
Turks & Caicos Islands
U.S. Outlying Islands
U.S. Virgin Islands
United Arab Emirates
Wallis & Futuna
Role in Educational Activity: (Check all that apply)
Please describe expertise and years of training specific to the educational activity. (If the description of expertise does not provide adequate information, the Nurse Planner may request additional documentation.)
Brief Biography (1-2 paragraphs) for Advertising
By checking the box, you agree to the following terms of commitment with USLCA.
Present on an agreed upon topic, date, and time.
Provide all presentation materials and handouts 2 weeks prior to the presentation.
Notify USLCA of the need to cancel as soon as possible or a minimum of 48 hours prior to the scheduled presentation and allow announcements of speaker cancellation in a timely as well as appropriate manner.
Reschedule within 3 months of the original presentation date so as not to negatively reflect on USLCA or the speaker.
Fully comply with the International Code of Marketing Breast-Milk Substitutes as well as current WHA resolutions
Uphold the mission and vision of USLCA through my presentation.
** Mission: To advance the IBCLC with in the United States through leadership, advocacy, professional development and research.
** Vision: A nation where all families have access to IBCLC care as a foundation of optimal health and wellness.
Conflict of Interest
Please read the following conflict of interest statements in accordance with ANCC and IBCLE. You will be asked to disclose any conflicts of interest.
ANCC Conflict of Interest Statement:
The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity.
*Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients.
Commercial Interest Organizations are ineligible for accreditation.
An organization is NOT a Commercial Interest Organization* if it is:
• A government entity;
• A non-profit (503(c)) organization;
• A provider of clinical services directly to patients, including but not limited to hospitals, health care agencies and independent health care practitioners;
• An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to providers or developers of electronic health information systems, database systems, and quality improvement systems;
• A non-healthcare related entity whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on patients.
• A liability insurance provider;
• A health insurance provider;
• A group medical practice;
• An acute care hospital (for profit and not for profit);
• A rehabilitation center (for profit and not for profit);
• A nursing home (for profit and not for profit);
• A blood bank; or
• A diagnostic laboratory.
(*Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 (www.accme.org) - ANCC’s definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition)
All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.
**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.
• Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.
• Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
• Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.
Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?
If yes, indicate all actual, potential, or perceived conflicts of interest.
**All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.
Speakers Bureau description
Please type your name and the date as acknowledgment of accurate completion of the information given above.
IBCLE Speaker Disclosure & Conflict of Interest Declaration
It is the policy of the IBLCE to make best efforts to insure balance, independence, objectivity, and scientific rigor in all programs, which qualify for Continuing Education Recognition Points (CERPs).
Consequently, all speakers/presenters participating in any program for which CERPs are awarded are expected to disclose to the program audience any affiliations that may have a bearing on the subject matter of their presentation. Such affiliations include, but are not limited to:
• companies and commercial entities as defined in the IBLCE Minimizing Commercial Influence on Education Policy
• 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 to ensure that any real or 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 the information presented.
It is the responsibility of the Program Provider to distribute, collect and retain completed Speaker Disclosure & Conflict of Interest Declaration Forms from each speaker on the program schedule. Furthermore, it is the Program Provider’s responsibility to print any disclosures made by Speakers in the program materials and to provide IBLCE, upon request, with copies of the completed disclosure forms. Failure to comply with these requirements may result in denial of CERPs credit from IBLCE.
Possible types of affiliation include: grant/research support; receipt of honorarium, travel or other benefits; acting as a consultant/independent contractor, employee officer, director, or owner of a self‐managed equity interest; participation as par to 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.
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.
Please type your name and the date as acknowledgment of accurate completion of the information given within this application.
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