Accredited Approval Unit Individual Activity Application

Virginia Nurses Association Individual Educational Activity Application

2015 Criteria

Directions: Applicants interested in submitting an individual educational activity for approval must first complete the Individual Activity Applicant Eligibility Verification Form. After successful completion of the Individual Activity Applicant Eligibility Verification Form the applicant must complete this application. The application should be completed by typing directly into the PDF fillable form and attaching all requested documents. Directions on how to attach a document can be found in the attachments section. Applications must be submitted with payment to our Individual Activity Application Portal.

Individual Activity Application fees can be found here. Applications will not be reviewed until receipt of payment. All fees are non-refundable. Applicants are highly encouraged to submit payment electronically for the quickest processing time. If you will pay by check, please submit your Individual Activity Application electronically, make the check payable to Virginia Nurses Association, include the name of your organization and the name of your Individual Activity on the check, and mail payment to: Attn: VNA Accredited Approval Unit IAA Payment Virginia Nurses Association 6912 Three Chopt Road, Suite H. Richmond, VA 23226

If you have questions or need assistance with this process, please call 804-282-1808.

Helpful Tips: • Is your activity continuing nursing education? If the learning activity is intended to build upon the

educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to improve the health of the public and RNs’ pursuit of their professional career goals, then it is continuing nursing education.

• Review the Resources for completing an Individual Activity Application on the IndividualActivity Webpage.

• Your educational activity should be developed to address a professional practice gap, which isa change, problem, or opportunity for improvement in nursing practice.

• The desired learning outcome is the outcome you want learners to achieve after participatingin your educational activity. The desired learning outcome for your activity should be developed based on the professional practice gap and the educational need/s identified. The desired learning outcome should be written as a measure you want to achieve and you should be able to measure whether it is achieved using your evaluation method.

• Be sure to attach all documents listed under Attachments.• Once approved, your activity may be provided as many times as you choose during the two

year approval period as long as you do not make significant changes to the content and you report any changes in faculty to VNA.Please note: If you will be advertising this activity prior to approval, the following statement may be used: This activity has been submitted to the Virginia Nurses Association for approval to award contact hours. The Virginia Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

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https://form.jotform.com/53494192102956https://form.jotform.com/53165131087148https://form.jotform.com/53165131087148http://www.virginianurses.com/Main-Menu-Category/Education/For-Individual-Activity-Approvals/Single-Education-Activity-Forms.htmlhttp://www.virginianurses.com/Main-Menu-Category/Education/For-Individual-Activity-Approvals#PORTALhttp://www.virginianurses.com/Main-Menu-Category/Education/For-Individual-Activity-Approvals#PORTAL

ANCC IAA Template VNA 1.2018

Applicant’s Name (Organization or Individual): Address or Web Address of Organization/Individual: Identify Organization Type:

Constituent member association of ANA Multi-disciplinary educational group College or University Professional nursing education group Healthcare facility Specialty nursing organization Health-related organization Other:

Title of Activity: Date Form Completed: Activity Type: ☐Provider-directed, provider-paced: Live (Ex. In-Person Course or Webinar)

• Date of live activity: • Location of activity: • Number of contact hours to be awarded and method of calculation:

☐Provider-directed, learner-paced: Enduring material (Ex. Recorded Webinar/Course, CE Article)

• Start date of enduring material: • Expiration/end date of enduring material: • Number of contact hours to be awarded and method of calculation:

☐Learner-directed, learner-paced: Enduring material

• Start date of enduring material: Expiration/end date of enduring material:

• Number of contact hours to be awarded and method of calculation:

☐Blended activity • Date(s) of prework and/or post-activity work: • Date of live portion of activity: • Number of contact hours to be awarded and method of calculation:

Nurse Planner contact information for this activity: Name and credentials: Email Address: Phone Number:

The VNA Accredited Approval Unit will use the email address provided for the Nurse Planner for all communication regarding the status of this application.

The Nurse Planner must be a registered nurse who holds a current, unencumbered nursing license (or international equivalent) AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education activity.


A. Description of the professional practice gap (e.g. change in practice, problem in practice, opportunity for improvement) Describe the current state: (What is currently being done?)

Describe the desired state: (What do you want to achieve?)

Identified gap: (Change in practice, problem in practice, or opportunity for improvement that the educational activity will address to move from the current state to the desired state)

B. Evidence to validate the professional practice gap (check all methods/types of data that apply) ☐ Survey data from stakeholders, target audience members, subject matter experts or similar ☐ Input from stakeholders such as learners, managers, or subject matter experts ☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement ☐ Evaluation data from previous education activities ☐ Trends in literature, law and health care ☐ Direct observation ☐ Other—Describe:

Please provide a brief summary of data gathered that validates the need for this activity:

C. Educational need that underlies the professional practice gap (e.g. knowledge, skill and/or practices)

Gap in Knowledge (knows) Gap in Skills (knows how) Gap in Practice (shows/does) Other


D. Description of the target audience. (You can select more than one target audience). All RNs Advanced Practice RNs RNs in Specialty Areas (Identify Specialty): LPNs Interprofessional (Describe): Other (Type here):

E. Desired learning outcome(s) (What will the outcome be as a result of participation in this activity?)

Area of impact (check all that apply): ☐ Nursing Professional Development ☐Patient Outcome ☐ Other- Describe:

F. Outcome Measure(s) (A quantitative statement as to how the desired learning outcome of this activity will be measured):

G. Content of activity: A description of the content with supporting references or resources ☐ Describe content and include time calculation for content:

☐ If the activity is 3 hours or more, attach the agenda for the entire activity, including time calculation for the content, and leave the space above blank.

*Please note that introduction and breaks do not count towards contact hours. Time spent in theevaluation of the learning activity, discussion of the educational content, Q&A, and other engagement activities may be included in the total time when calculating contact hours. *60 minutes=1 Nursing Contact Hour*Please describe the method used for calculating contact hours (ex. Pilot study, historical data,complexity of content, mergener formula, etc.)


Content for this educational activity was chosen from: Please provide specific resources that will be used to develop the content. Please do not solely list expert resource(s). The knowledge of your expert resource(s) must be supported by additional evidence based material. ☐ Information available from the following organization/web site (organization/web site must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content; examples – Agency for Healthcare Research and Quality, Centers for Disease Control, National Institutes of Health):

☐ Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years):

☐ Clinical guidelines:

☐ Expert resource (individual, organization, educational institution) (book, article, web site):

☐ Textbook reference:

☐ Other:

H. Learner engagement strategies

☐ Integrating opportunities for dialogue or question/answer ☐ Including time for self-check or reflection ☐ Analyzing case studies ☐ Providing opportunities for problem-based learning ☐ Other:

http://www.guidelines.gov/


I. Criteria for Awarding Contact Hours Criteria for awarding contact hours for live and enduring material activities include:

(Check all that apply) ☐ Attendance for a specified period of time (e.g., 100% of activity, or miss no more than

10 minutes of activity) - Describe: ☐ Credit awarded commensurate with participation ☐ Attendance at 1 or more sessions ☐ Completion/submission of evaluation form ☐ Successful completion of a post-test (e.g., attendee must score % or higher) ☐ Successful completion of a return demonstration ☐ Other - Describe:

J. Description of evaluation method: How will change in knowledge, skills, and/or practice be evaluated at the end of this activity? (Refer back to identified practice gap and educational need – evaluation must occur at the level of need identified in “C” above) Describe the tools/methods you will use.

Short-term evaluation options: ☐ Intent to change practice ☐ Active participation in learning activity ☐ Post-test ☐ Return demonstration ☐ Case study analysis ☐ Role-play ☐ Other – Describe:

Long-term evaluation options: ☐ Self-reported change in practice ☐ Change in quality outcome measure ☐ Return on Investment (ROI) ☐ Observation of performance ☐ Other – Describe:


ATTACHMENTS

Please provide evidence of the following by attaching the supporting documents here:

Attachment 1 Names and credentials of all individuals in a position to control content: You must identify the individuals who fill the roles of Nurse Planner and content expert(s). You may complete the chart below and attach an additional spreadsheet if needed.

Attach additional spreadsheet Here: ________

Attachment 2 Conflict of Interest Documentation Form: from all individuals in a position to control content (e.g. planners, presenters, faculty, authors, and/or content reviewers) and resolution if applicable. Please use the provided Conflict of Interest Documentation Form. The Nurse Planner must complete section 6 and sign for all forms.

Attach Here: ________

*If you are planning an interprofessional continuing education activity the CME Disclosure ofFinancial Relationships Form may be used in place of the Conflict of Interest Documentation Form. The Nurse Planner must attach an additional document stating he/she has reviewed all Disclosures of Financial Relationships, document if any conflicts exist, state how the conflicts were resolved, and sign.

*If the content of the activity has no relationship to products or services of a commercial entity,(Examples: Content on Leadership Development, Workplace Violence) the Nurse Planner may attach a statement that COI documentation is not required because the content of the activity has no relationship to products or services of a commercial entity (consumed by or used on patients). You may review the definition of a commercial interest organization in the ANCC Content Integrity Standards. *Applicants are required to contact the VNA before submitting an application with this statement to ensure conflict of interest assessment is not required.

Attachment 3 Agenda: If the activity is longer than 3 hours, attach the Agenda for the entire activity, including time calculation for the activity.


Attachment 4 Documentation of Completion and/or Certificate: Must include:

• Title and date of the educational activity• Name and address of the provider of the educational activity (web address

acceptable)• Number of contact hours awarded• Space for participant’s name• Activity approval statement: This continuing nursing education activity was approved

by the Virginia Nurses Association an accredited approver by the American NursesCredentialing Center’s Commission on Accreditation.

A sample may be found under Application Forms.

Double click the paperclip to learn how to attach documents and open the forms below.

http://www.nursecredentialing.org/accreditation-cecontentintegrity.pdfhttp://www.virginianurses.com/Main-Menu-Category/Education/For-Individual-Activity-Approvals
How to attach a file into a PDF.

Click on View

Click on Comments then Annotation

Click on the paperclip located in the right tool box.

Add attachment: select what file you want to attach

Your attachment will show up on the PDF

JackieFile AttachmentHow to attach a file into a PDF.docx

AA - Individual Activity COI Form, 2017 criteria, 9.27.17

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Virginia Nurses Association

Conflict of Interest Form

2015 Criteria

Title of Educational Activity: Education Activity Date: Role in Educational Activity: (Check all that apply) Nurse Planner

Content Expert

Faculty/Presenter/Author

Content Reviewer

Other – Describe:

Section 1: Demographic Data

Name with Credentials/Degrees: ________________________________________________________ If RN, Nursing Degree(s): AD Diploma BSN Masters Doctorate Address: ___________________________________________________________________________ Phone Number: ______________________________ Email Address: ________________________ Current Employer and Position/Title: _____________________________________________________

Section 2: Conflict of Interest 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;


Page 2 of 4

• 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.

• Liability insurance providers

• Health insurance providers

• Group medical practices

• Acute care hospitals (for profit and not for profit)

• Rehabilitation centers (for profit and not for profit)

• Nursing homes (for profit and not for profit)

• Blood banks

• Diagnostic laboratories

(*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.


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Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?

Yes No

If yes, complete the table below for all actual, potential or perceived conflicts of interest**:

Check all that apply

Category Description

Salary

Royalty

Stock

Speakers Bureau

Consultant

Other

** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.

Section 3: Statement of Understanding

Completion of the line below serves as the electronic signature of the individual completing this

Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

________________________________________________________ _________________________

Typed or Electronic Signature: Name and Credentials (Required) Date


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Section 4: Conflict Resolution (to be completed by Nurse Planner)

A. Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply)

Not applicable since no conflict of interest. Removed individual with conflict of interest from participating in all parts of the educational activity. Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the

educational activity.

Not awarding contact hours for a portion or all of the educational activity. Undertaking review of the educational activity by Nurse Planner/content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND

monitoring the educational activity to evaluate for commercial bias in the presentation.

Undertaking review of the educational activity by Nurse Planner/content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND

reviewing participant feedback to evaluate for commercial bias in the activity.

Other - Describe:

Nurse Planner Signature (* If form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign the form).

Completion of the line below serves as the electronic signature of the Nurse Planner reviewing

the content of this Conflict of Interest Form

________________________________________________________ __________________

Typed or Electronic Signature: Name and Credentials (Required) Date

Address:

Name with CredentialsDegrees:

Phone Number:

Email Address:

Current Employer and PositionTitle:

DescriptionSalary:

DescriptionRoyalty:

DescriptionStock:

DescriptionSpeakers Bureau:

DescriptionConsultant:

DescriptionOther:

Date:

AND reviewing participant feedback to evaluate for commercial bias in the activity:

Date_2:

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LindseyFile Attachment2018 VNA COI Form.pdf


Completed by: Date:

Attachment 5 Commercial Support Agreement (if applicable):

Commercial Support is financial or in-kind contributions given by a commercial interest that are used to pay for all or part of the costs of a continuing nursing education activity.

If the educational activity will receive commercial support, a Commercial Support agreement must be completed, signed, and dated by the commercial interest organization and provider of the educational activity. If multiple commercial interest organizations will provide support, an agreement is required for each commercial interest organization. If you are unsure as to whether the organization providing support is a commercial interest, please refer to the definition of a commercial interest provided in the ANCC Content Integrity Standards or contact the VNA.

Will Commercial Support be provided? Yes No Attach Here: ________

Attachment 6 Disclosures: Evidence of required information provided to learners prior to start of the educational activity:

1. Activity approval statement as issued by the accredited approver: Thiscontinuing nursing education activity was approved by the Virginia NursesAssociation an accredited approver by the American Nurses CredentialingCenter’s Commission on Accreditation.

2. Criteria for successful completion in order to receive contact hours3. Presence or absence of conflicts of interest for all individuals in a position to

control content (e.g. the Planning Committee, presenters, faculty, authors, andcontent reviewers) If COI is present, disclosure must include name of person,type of relationship, and name of commercial entity.

4. Commercial support (if applicable)5. Expiration date (enduring materials only)6. Name(s) of Joint Provider(s) (if applicable)

NOTE: Materials associated with the activity (marketing materials, advertising,agendas, and certificates of completion) must clearly indicate the Providerawarding contact hours and responsible for adherence to ANCC criteria)

Disclosures can be provided via printed materials, verbally, via presentation slide, or a combination of methods but must be disclosed prior to the start of the program. Applicants are required to provide a document showing the disclosures that will be made. A sample may be found under Application Forms.

Attach Here: ________ Attachment 7 Summative evaluation:

The VNA requires submission of a Summative Evaluation, within 30 days of your educational activity. The evaluation summary should be specific to the evaluation method/tool used and demonstrate if the desired learning outcome was met (Ex. Summary of pre/post test results, summary of case study or simulation performance, summary of new knowledge obtained, summary of intent to change practice survey, etc.).
http://www.nursecredentialing.org/accreditation-cecontentintegrity.pdfhttp://www.virginianurses.com/Main-Menu-Category/Education/For-Individual-Activity-Approvalshttps://form.jotform.com/60106345905955

ANCC IA Commercial Support Agreement VNA 1.2018 Page 1 of 2

Virginia Nurses Association Individual Activity Applicant

Commercial Support Agreement

A commercial interest, as defined by the American Nurse's Credentialing Center (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. Nonprofit or government organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests.

Commercial support is financial or in-kind contributions given by a commercial interest that are used to pay for all or part of the costs of a CNE activity.

Note: Organizations providing commercial support may not provide or joint provide an educational activity.

Title of Educational Activity:

Activity Location (if live): Activity Date (if live): Name of Commercial Interest Organization:

Name of Individual Activity Applicant:

Total amount of Commercial Support:

Complete description of all Commercial Support provided including both financial and in-kind support:

Please check all that apply:

Unrestricted

Restricted* o Speaker honorariao Speaker expenseso Mealo Other (please list):

* Commercial interest may request that funds be used to support a specific part of an educational activity. TheIndividual Activity Applicant may choose to accept the restriction or not accept the commercial support. The Individual Activity Applicant maintains responsibility for all decisions related to the activity as described below.

Terms and Conditions

1. All organizations must comply with the ANCC Content Integrity Standards for Industry Support in Continuing Educational Activities which is available on the ANCC Accreditation web page.

2. This activity is for educational purposes only and will not promote any proprietary interest of aCommercial Interest organization providing financial or in-kind support.

▪ The CIO will not recruit learners from the educational activity for any purpose

3. The Individual Activity Applicant is responsible for all decisions related to the educational activity. The Commercial Interest organization providing financial or in-kind support may not participate in any component of the planning process or implementation of an educational activity, including:

ANCC IA Commercial Support Agreement VNA 1.2018 Page 2 of 2

▪ Assessment of learning needs and professional practice gap▪ Learning outcomes▪ Selection or development of content▪ Selection of planners, presenters, faculty, authors and/or content reviewers▪ Selection of teaching/learning strategies▪ Evaluation methods

4. The Individual Activity Applicant will make all decisions regarding the disposition and disbursement of commercial support in accordance with ANCC criteria.

5. All commercial support associated with this activity will be given with the full knowledge and approval of the Individual Activity Applicant. No other payments shall be given to any individuals involved with the supported educational activity.

6. Commercial support will be disclosed to the participants of the educational activity.

7. Commercial Interest Organizations may not exhibit, promote or sell products or services during the introduction of an educational activity, while the educational activity takes place or at the conclusion of an educational activity, regardless of the format of the educational activity.

Statement of Understanding

An “X” in the boxes below serves as the electronic signatures of the representatives duly authorized to enter into agreements on behalf of the organizations listed and indicates agreement of the terms and conditions listed in the Commercial Support Agreement above.

Individual Activity Applicant Name:

Address:

Name of Representative:

Email Address:

Phone Number:

Fax Number:

__________________________________ Electronic Signature (Required) Date:

Completed By: (Name and Credentials)

Commercial Interest Name:

Address:


Email Address:

Phone Number:

Fax Number:

__________________________________ Electronic Signature Type Name (Required) Date: Completed By: (Name and Credentials)

Title of Educational Activity:

Activity Location if live:

Activity Date if live:

Name of Commercial Interest Organization:

Name of Individual Activity Applicant:

Total amount of Commercial Support:

Individual Activity Applicant Name:

Address:


Email Address:

Phone Number:

Fax Number:

Completed By Name and Credentials:

Commercial Interest Name:

Address_2:

Name of Representative_2:

Email Address_2:

Phone Number_2:

Fax Number_2:

Completed By Name and Credentials_2:

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LindseyFile Attachment2018 VNA IA Commercial Support Agreement.pdf


Attachment 1 Individuals in a Position to Control Content

Complete the table below for each person in a position to control content of the educational activity and include name, credentials, educational degree(s), role on the planning committee, and if they have a commercial interest relationship. There must be one Nurse Planner and one other planner to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert). The individuals who fill the roles of Nurse Planner and Content Expert must be identified under Individual’s Role in Activity below. Please list all other individuals involved in planning the activity as well as any faculty, presenters, authors, or content reviewers. Names and credentials of all individuals in a position to control content (must identify the individuals who fill the roles of Nurse Planner and content expert(s)).

Name of individual and credentials

Individual’s role in activity Planning committee member? (Yes/No)

Name of commercial interest

Nature of relationship

Example: Jane Smith, RN-BC Nurse Planner Yes None ---

Example: Sue Brown, RNC Content Expert Yes None ---

Example: John Doe, PhD Presenter No Pfizer Speakers Bureau

fill_1: fill_2: fill_3: or higher: Example Jane Smith RNBC: Individuals role in activity: Nature of relationship: Nurse Planner: Yes: None: undefined: Content Expert: Yes_2: Pfizer: Speakers: Example John Doe PhDRow1: PresenterRow1: NoRow1: PfizerRow1: Speakers BureauRow1: Example John Doe PhDRow2: PresenterRow2: NoRow2: PfizerRow2: Speakers BureauRow2: Example John Doe PhDRow3: PresenterRow3: NoRow3: PfizerRow3: Speakers BureauRow3: Example John Doe PhDRow4: PresenterRow4: NoRow4: PfizerRow4: Speakers BureauRow4: Example John Doe PhDRow5: PresenterRow5: NoRow5: PfizerRow5: Speakers BureauRow5: Example John Doe PhDRow6: PresenterRow6: NoRow6: PfizerRow6: Speakers BureauRow6: Example John Doe PhDRow7: PresenterRow7: NoRow7: PfizerRow7: Speakers BureauRow7: Example John Doe PhDRow8: PresenterRow8: NoRow8: PfizerRow8: Speakers BureauRow8: Example John Doe PhDRow9: PresenterRow9: NoRow9: PfizerRow9: Speakers BureauRow9: Example John Doe PhDRow10: PresenterRow10: NoRow10: PfizerRow10: Speakers BureauRow10: Example John Doe PhDRow11: PresenterRow11: NoRow11: PfizerRow11: Speakers BureauRow11: Example John Doe PhDRow12: PresenterRow12: NoRow12: PfizerRow12: Speakers BureauRow12: Example John Doe PhDRow13: PresenterRow13: NoRow13: PfizerRow13: Speakers BureauRow13: Example John Doe PhDRow14: PresenterRow14: NoRow14: PfizerRow14: Speakers BureauRow14: Example John Doe PhDRow15: PresenterRow15: NoRow15: PfizerRow15: Speakers BureauRow15: Text1: Text2: Text3: Text4: Check Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffText22: Text23: Text24: Text25: Text27: Text28: Text29: Text37: Check Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffText44: Text45: Text46: Text47: Check Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck Box71: OffCheck Box72: OffCheck Box73: OffCheck Box74: OffCheck Box75: OffCheck Box76: OffCheck Box77: OffCheck Box78: OffCheck Box79: OffCheck Box80: OffCheck Box81: OffCheck Box82: OffCheck Box83: OffCheck Box84: OffText85: Text86: Text87: Text88: Text89: Text90: Text91: Text92: Text93: Check Box94: OffCheck Box95: OffCheck Box96: OffCheck Box97: OffCheck Box98: OffCheck Box99: OffCheck Box100: OffCheck Box101: OffCheck Box102: OffCheck Box103: OffCheck Box104: OffCheck Box105: OffCheck Box106: OffCheck Box107: OffCheck Box108: OffText5: Text6: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text7: Text18: Text19: Text20: Text21: Text26: Text30: Text31: Text32:

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