Forms for Coordinators

RSS Application 2021-2022

Please note:

Conflict of Interest Disclosure Form

All presenters and planning committee members must complete the COI form PRIOR to the event.

Resolution of Conflict of Interest

This form must be completed by the course director PRIOR to the event if a presenter or planning committee member discloses financial relationship with an ineligible company.

RSS Activity Description Form

This form must be completed by a lecture-based event speaker to indicate his/her demographics, presentation title, and objectives.

Accreditation and Credit Designation Statement

All announcements should have the following accreditation and credit designation statement – verbatim, punctuated and formatted exactly as shown below.

The second paragraph should include the correct number of credit(s) where indicated.

Download Joint Accredited Provider logo here

JA Provider MarkIn support of improving patient care, University of Nebraska Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 The University of Nebraska Medical Center designates this live activity for a maximum of X.XX AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Visiting Faculty Funding Form

This form must be completed by the RSS Coordinator if a speaker is receiving any form of reimbursement.

RSS Patient-Based Monthly Report