Speaker Information and Disclosure Form | Louisiana Chapter of the American Academy of Pediatrics

Speaker Form Updated 2024

Step 1 of 2

Speaker Information

Name/ Credentials(Required)

First Last Credential

Phone(Required)

Email(Required)

Event/Series Title

Planning Organization

Mailing Address

Mailing address will be used to send honoraria to speakers when applicable.

Street Address Address Line 2 City State ZIP Code

Assistant Information (If Relevant)

Name Phone number Email address

Please share a brief 2-4 sentence bio(Required)

Please include your current role(s) and main areas of interest. Include connection to educational topic if applicable.

CV(Required)

Please upload a current CV

Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.

Professional Headshot

Please upload a current photo for advertising

Drop files here or

Accepted file types: jpg, png, Max. file size: 50 MB.

Disclosure

As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form below by submitting this form. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at CME@laaap.org or (225) 379-7932.

Ineligible Companies

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.

Relationships

Please disclose ALL financial relationships that you have had in the past 24 months with ineligible companies (see definition above). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education. • Please note: If adding more than one ineligible company, click the + on the right.

Ineligible Company Name

Nature of Relationship

Has the Relationship Ended?

Attestation Date(Required)

By filling in the date below and submitting the form, I attest that the above information is correct as of this date of submission. • Disclosures are valid for 1 year from submission.