Speaker Information and Disclosure Form Speaker Form Updated 2024 Step 1 of 2 50% Speaker InformationName/ Credentials(Required) First Last Credential Phone(Required)Email(Required) Event/Series Title Planning OrganizationLouisiana AAPArkansas AAPMississippi AAPWillis Knighton Health SystemLouisiana Healthcare ConnectionsLouisiana Department of HealthLouisiana Dermatological SocietyShots for Tots LouisianaOtherMailing AddressMailing address will be used to send honoraria to speakers when applicable. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Select files Accepted file types: pdf, Max. file size: 50 MB. Professional HeadshotPlease upload a current photo for advertising Drop files here or Select files Accepted file types: jpg, png, Max. file size: 50 MB. DisclosureAs 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 CompaniesAn 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. RelationshipsPlease 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 NameNature of RelationshipHas the Relationship Ended? Add RemoveNo Relationships In the past 24 months, I have not had any financial relationships with any ineligible companies.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. Month Day Year Δ
