Ninth Annual 2010 Summer Institute on Evidence-Based Practice

July 8-10, 2010 Institute (July 7 Pre Conferences) Hyatt Regency Riverwalk Hotel, San Antonio, Texas

Abstract Submitted for Summer Institute on EBP

Educators’ EBP Workshop®

See specific format at ***2010 Summer Institute on Evidence-Based Practice*** Use separate forms for each abstract Title of Abstract/Poster Presentation: (65 characters)

This information has been previously disseminated: No Yes If presented previously, please specify When and Where:

Name of Presenter (first, middle, last) Credentials (e.g., PhD, RN, MD)

Professional Title: Affiliation:

Home Address: Work Address:

Home Phone: Work Phone: Fax #: Email Address: List other project members here: (name, credentials, professional title, affiliation, fax #, email address)

If selected, I agree to present my poster and I give permission for duplication of my abstract for inclusion in the conference syllabus and online proceedings. I understand that registration is required for abstract presenters.

Signature: Primary Presenter’s signature (typing in your name acts as your signature) Send your 4-part abstract packet containing 1) cover sheet 2) biographical data 3) conflict of interest disclosure and 4) abstract (insert as last page of packet) to: [email protected] . Indicate in the subject line of your email whether your abstract is a “Summer Institute Abstract Packet” or “Educators’ EBP Workshop® Abstract Packet”. Biographical Data Form The University of Texas Health Science Center at San Antonio 2010 Summer Institute on Evidence Based Practice

Instructions: Use this format to provide documentation of an individual’s expertise as a planning committee member or as a presenter (content specialist) for this activity. Submitted information must not be more than 2 pages. Do not attach any additional material.

Name: (Name and Degrees)

Preferred Contact Address: (Number and Street)

(City, State and Zip Code)

Preferred Contact Telephone: and work

E-mail Address:

Present Employee and Position Job Title:

Education (include basic preparation through highest degree held) Degree Institution Name Major Area of Study Year City, State Degree awarded

Biographical Data: RN Nurse Planner Presenter (Poster) Content Specialist Speaker Target Audience Representative Other: REQUIRED: The summary is used to document your experience as it relates to your role in this continuing nursing education activity, e.g., RN planner, presenter (poster), content specialist, target audience representative, etc.

Conflict of Interest Disclosure Form The University of Texas Health Science Center at San Antonio 2010 Summer Institute on Evidence Based Practice As an approved provider by the Texas Nurses Association, it is the policy of The University of Texas Health Science Center at San Antonio to ensure balance, independence, objectivity and scientific rigor in all of its continuing nursing education activities. All planning committee members and presenters/content specialists/authors participating in a The University of Texas Health Science Center at San Antonio activity must disclose to The University of Texas Health Science Center at San Antonio any financial relationships that they or an immediate family member may have with any commercial interest in any amount occurring within the past 12 months that create a conflict of interest. An “immediate family member” is defined as someone with whom you have a relationship involving the sharing of income or assets. The intent of this disclosure is not to prevent a speaker with commercial affiliations from presenting, but rather to inform The University of Texas Health Science Center at San Antonio of any financial relationships so that conflicts can be resolved prior to the activity.

Name: For all disclosures, complete each section, sign and date the last page. Please spell out all acronyms.

I or an immediate family member have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the following categories: 1. Employment No, I do not have an employment relationship with a commercial interest to disclose. Yes, I have an employment relationship with 2. Board of Directors/Other Leadership Position No, I do not have a leadership position with a commercial interest to disclose. Yes, I have a leadership relationship with 3. Research Funding No, I do not have research funding from a commercial interest to disclose. Yes, I receive research funding from 4. Paid Consultant or Member of an Advisory Board or Review Panel No, I do not have a consultant or advisory position to disclose. Yes, I have a consultant or advisory board relationship with 5. Speaker’s Bureau No, I am not on a speaker’s bureau for a commercial interest. Yes, I am on the speaker’s bureau(s) for 6. Major Stock or Investment Holder No, I do not have major stock or investment holdings to disclose. Yes, I have stock holdings with 7. Other Remuneration No, I do not have other compensation to disclose. Yes (please list relationship and company name) 8. Off label use of drugs No, I will not discuss off label use of drugs. Yes I will discuss off label use of drugs.

FDA APPROVED DRUG AND DEVICES ASSURANCE STATEMENT

The University of Texas Health Science Center at San Antonio is required by the TNA and ANCC COA guidelines to instruct you that any discussions regarding the utilization of FDA approved drugs or devices must be within approved regulations. If you discuss the utilization of FDA drugs or devices that are outside approved regulations (off-label or investigational uses), you must clearly delineate this for your audience.

Electronic Signature of Person Disclosing: Date: Email this form to [email protected] from the email address of the person signing .

For The University of Texas Health Science Center at San Antonio RN Nurse Planner use Only: Resolution of potential conflicts: No relevant relationship(s) to resolve Provided talking points/outline Restricted presentation to clinical data Data, slides added or removed Reassigned faculty’s lecture/topic Reviewed content – free of commercial bias

Notes: ______

Signature of RN Nurse Planner: ______Date: ______

Glossary of Terms for Conflict of Interest Disclosure form

Commercial Interest ANCC defines an entity that has a “commercial interest” as any proprietary entity producing health care goods or services, with the exception of non-profit or government organizations.

Conflict of Interest ANCC defines a “conflict of interest” as when an individual has an opportunity to affect CNE content with products or services from a commercial interest with which he/she has a financial relationship. ANCC considers “opportunity to affect CNE content” to include content about specific agents/devices, but not necessarily about the class of agents/devices, and not necessarily content about the whole disease class in which those agents/devices are used.

Financial relationships ANCC defines “financial relationships” as those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual finds), or other financial benefit. Financial relationships can also include ‘contracted research’ where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advsory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ANCC considers relationships of the person involved in the CNE activity to include financial relationships of a family member.

Off label Using products for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Relevant financial relationships ANCC considers financial relationships in any amount occurring within the past 12 months as “relevant” in terms of creating a conflict of interest.

Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities (please specify).

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

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