Educational Event in Which You are Speaking/Planning/Reviewing(Required)
Individual's prospective role(s) in education(Required)
Identify the prospective role(s) that you have in the planning and delivery of this education (choose all that apply)


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 or (225) 379-7932.

To be completed by Planner, Faculty, or Others Who May Control Educational Content

Please disclose ALL financial relationships that you have had in the past 24 months with ineligible companies (see definition below). 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.
Ineigible Company(s)
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 Please note: If adding more than one ineligible company, click the + on the right
Name of Ineligible Company
Nature of Financial Relationship
Has the relationship ended?
By filling in the date below and submitting the form, I attest that the above information is correct as of this date of submission.
MM slash DD slash YYYY

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