CME Role(s) *

Please choose all that apply.

ACE Presenter, Moderator, Panelist, other role for a Conference, Symposium, etc.

ACE Presenter, Moderator, Panelist, other role for Live Internet

ACE Presenter, Moderator, Panelist, other role for a Regularly Scheduled Series

ACE Presenter, Moderator, Panelist, other role for activity

ACE Planner, Content Reviewer, Presenter, Moderator, Panelist: Enduring Material

I am personally receiving an honorarium for this activity. *

Yes

No

Please check the correct statement below: *

Please choose only one answer

I have NO relevant financial relationships with any ineligible companies.

Within the past 24 months I, the undersigned, do have a relevant financial arrangement or affiliation with the organizations/companies noted below.

I agree to the below statements: *

I have disclosed to Alabama Chapter-AAP/Children's of Alabama all relevant financial relationships. If I am a presenter for a lecture/didactic session, I will also disclose these relationships to learners (verbally, through a slide, etc.), so they may form their own opinions as to possible bias in either exposition or conclusion. I am aware Alabama Chapter-AAP/ Children's of Alabama will disclose this information to learners through additional means and, where evaluation forms are used, ask participants to indicate their opinions regarding possible bias.

Should I be involved in Alabama Chapter-AAP/ Children's of Alabama ACE topic or content development and/or presentation of information, my involvement will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of ineligible companies. Any Alabama Chapter-AAP/Children's of Alabama content with which I am involved, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.

I will not accept honoraria, payments or reimbursements related to Alabama Chapter-AAP/ Children's of Alabama ACE, unless agreed upon directly with the Alabama Chapter-AAP/ Children's of Alabama.

I understand that Children's of Alabama or Alabama Chapter-AAP may request to review my presentation and/or content prior to the activity. I will provide educational content and resources in advance if requested.

I understand that participants may be asked to evaluate whether my contribution to a ACE event(s) is educational, and not promotional, in nature.

If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.

If I am providing patient care recommendations, all supporting scientific research I use, report or to which I refer, will conform to the generally accepted standards of experimental design, data collection and analysis.

If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available and not just trade names from any single company.

If I have been trained or used as a speaker by a ineligible companies or its agent (e.g., speaker's bureau) for any ineligble companies, the promotional aspects of that presentation will not be included in any way with this activity.

If I am presenting research funded by a ineligble companies, the information presented will be based on generally accepted scientific principles and methods and will not promote the ineligible companies of the funding company.

Other Internet or Enduring Material(s) presenter:

Please complete this section if you will be presenting or creating content for an internet or enduring material OTHER than Children’s of Alabama Pediatric Grand Rounds

I hereby consent to Children’s of Alabama link to the created Internet modules on the Internet and the staff accessible Intranet.

I hereby consent to Children’s of Alabama linking to the created web module(s) for future educational viewing and to include the module(s) as an Enduring Material for a period of up to three years.

I grant Children’s of Alabama an unlimited, irrevocable, royalty free license to use the recorded presentation for continuing medical education.

I understand that a hard copy of each slide/module presentation kept by the ACE Department as part of the ACE activity file for potential audit purposes and that each slide/module presentation will otherwise not be distributed.

I acknowledge that I have in place a valid authorization signed by the patient or patient’s representative any necessary permission to use photographs and/or videotape and have that authorization on file.

I have carefully read and considered each item above and have responded to the best of my ability. *

Yes

No