Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Conflict of Interest: Exception Request

University of Nevada, Reno School Of Medicine
Conflict of Interest Policy
Exception Request Related to Teaching or Clinical Activities

Conflicts of interest are common situations and manageable in academic medicine. This form allows the University of Nevada, Reno School of Medicine COI review committee to manage potential conflicts in educational or clinical settings.

For an Education or Clinical activity exception, complete this form at least four weeks prior to the event so the School of Medicine COI committee can review and respond to your request. If the exception is approved, the faculty person in charge will complete a brief following report on the activity or product and the impact it had on learners and/or patients.

If you have any questions regarding this form, please contact the Office of the Executive Associate Dean at (775) 682-7493.

Faculty Information

Faculty member requesting this exception*

First Name

Last Name

Department*

Phone*

Email*

Is the person named above the person filling out this form?*

Yes No

We strongly encourage the person engaging in the activity be the person that completes this form.

Form Submitter

Please identify the person filling out this form.

Submitter Name*

First Name

Last Name

Submitter Phone*

Submitter Email*

Activity Details

Who will benefit from this activity or product (number and type of patients, medical students, faculty, residents, etc.)? Please be specific.*

In what way(s) will they benefit?*

Describe the learning objectives from this activity or use of this product.*

Please describe the outcome measures for the activity or product, how you will evaluate the attainment of the outcome measures and attach the document(s) you will use to measure outcomes.*

Please note: Outcome measures are required for approval of exception.

Are there any special circumstances the committee should be aware of?

Supporting Document

No File Chosen

File uploads may not work on some mobile devices.

Include any supporting documents

Conflict of Interest: Exception Request

University of Nevada, Reno School Of MedicineConflict of Interest PolicyException Request Related to Teaching or Clinical Activities

Faculty Information

Form Submitter

Activity Information

Activity Details

University of Nevada, Reno School Of Medicine
Conflict of Interest Policy
Exception Request Related to Teaching or Clinical Activities