Annual Meeting Speaker Agreement

Speaker Agreement for
Ohio Chapter, American Academy of Pediatrics
Continuing Medical Education
Annual Meeting 2017

Section I - Personal Information

Name: *

First Name, Last Name & Credentials

AAP ID#

Email Address *

Cell Phone Number (for use by staff during the conference):

Address:

City:

State:

ZIP:

Section II - Important Deadlines

Please note the deadlines below:

CME Disclosure: 4/15/17
Marketing and Objectives: 4/15/17
PowerPoint Presentation – 10/2/17

Section III - Conflict of Interest and Faculty Disclosure:

A conflict of interest is considered to exist if an individual has both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest. A financial relationship includes all of the following as may relate to the individual, spouse, family member, partner or significant other: employment; royalty; intellectual property rights; consulting fees; honoraria; stocks or stock options, excluding diversified mutual funds; other financial benefit. Individuals who refuse to provide disclosures will be disqualified from participation in the CME activity.

Please visit to complete disclosure form:
CLICK HERE

Section IV - Conference Program, Online and Mobile App Listing:

Please type the following information exactly as you wish it to appear for your published faculty listing.

Full Name and Credentials

Primary Professional Title(s):

Primary Institutional Affiliation:

City:

State:

Section V - Introduction for Session Moderator:

In the space provided below (limit to 150 words or less), please provide us with a brief introduction for use by the session moderator. The moderator will introduce you/your session and will be available to field audience questions if you wish her/him to do so. If your name is difficult to pronounce, please spell it phonetically in the introduction as in the sample introduction provided below for your convenience.

Section VI: Marketing and Objectives

Objectives: Please provide 3 learning objectives for your presentation or panel involvement. Objectives will clearly and concisely communicate what an attendee is expected to know and/or do at the conclusion of an activity. Objectives must be included in the brochure so the attendees may evaluate the relevance of attending a CME activity.

Marketing: Please provide a short marketing paragraph that will be used to promote your session on the brochure, online and through social media.

Signature

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