Planner Disclosure Form
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.
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.
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.
Company Name
List all relationships you have had with this company over the past 24 months
Include Company name; relationships; have all relationships ended for each additional company.
Attestation of No Financial Relationships
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.