In compliance with the American Speech-Language Hearing Association's Continuing Education Board's Requirements, theTexas Speech-Language-Hearing Association (TSHA) requires program planners and instructional personnel to disclose information reqarding any relevant financial and non-financial relationships related to course content prior to and during course planning.
Based on the information provided, TSHA will engage the program plannerplanner/instructional personnel in a process which seeks to understand how the relevant financial or nonfinancial relationship may influence the content of the course.
Program Planner/Instructional Personnel's Name: Planner/Instructional Personnel's Name is required.
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HIPAA REQUIREMENTS   To comply with the Health Insurance Portability and Accountability Act (HIPAA), we ask that all program planners and instructional personnel insure the privacy of their patients/clients by refraining from using names, photographs, or other patient/client identifiers in course materials without the patient's/client's knowledge and written authorization.   I am in compliance with these policies: Initials are required.(INITIAL HERE)
Relevant financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, gift, speaking fee, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include "contracted research" where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Do you have relevant financial relationships to disclose? No Yes   Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. May also include personal interest or cultural bias.   Do you have relevant non-financial relationships to disclose? No Yes
I attest that the information in this disclosure is accurate at the time of completion and I agree to notify TSHA of any changes to this information between now and the presentation.
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