Speaker Information and Disclosure

Speaker Information and Disclosure

Full Name*

Credentials*

Phone Number*

Phone

Email*

Session Title*

Provider*

Select

Do you have an assistant or anyone else we should include in communication about this activity?*

yes

Assistant Name

Assistant Email

Bio*

Please write a brief--2-4 sentence--bio including your current role(s), main areas of interest, and connection to the educational topic. The may be used for promotion for this activity or read aloud before the session.

Write in third person, e.g. Dr. Kristin Smith is director of epidemiology at the Department of Health. She completed medical school and her PhD in epidemiology at Louisiana School of Medicine and trained in Infectious diseases at Millerville Hospital. She recently guided the development of the state virology information center.

Upload a current CV and Professional Headshot Here*

Drag and drop files here or

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.

How many companies have you had financial relationships with in the past 24 months?*

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; ACCME requires that you disclose all financial relationships, regardless of the amount, with ineligible companies.

You must disclose all financial relationships regardless of the potential relevance of each relationship to the education.

Select

Company 1

Company Name

Company 1 Nature of Relationship