STATE DUESH.E.L.P. FORM
Council of State Speech-Language-Hearing Association Presidents

Presenter Worksheet-Additional Speaker

CSAP Presentation Information Submission
(e.g., MS, CCC-SLP)

In compliance with American Speech-Language Hearing Association’s Continuing Education Board’s Requirements, the Council of State Speech-Language-Hearing Association Presidents requires program planners and instructional personnel to disclose information regarding any relevant financial and non-financial relationships related to course content prior to and during course planning.

Based on the information provided, the state association will engage the program planner/instructional personnel in a guided interview process which seeks to understand how the relevant financial or non-financial relationship may influence the content of the course.

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.
Yes, I am in compliance with these policies (Enter initials below):
Relevant financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, gift, speaking fee and/or travel support, 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. Other items considered relevant financial relationships: If you will be referencing where you work, discussing actual cases studies from your placement of employment, or referencing a product/book in which you receive royalties. Please see Financial Relationship Disclosure Section for a complete listing.
Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. Relevant non-financial relationships may also include personal interest, cultural bias, having a child or family member affected by the topic you are presenting. Please see Non-Financial Relationship Disclosure Section for a complete list of items to consider.
I attest that the information in this disclosure is accurate at the time of completion and I agree to notify the Speech-Language-Hearing Association of any changes to this information between now and the presentation/event. If you are a presenter, please prepare the first slide of your presentation as your disclosure slide. If receiving payments for an honorarium, travel support, etc. please do not list the payment amount. Reference only what you are receiving (honorarium, travel support, etc). Should you have no relevant or non-relevant financial relationships to disclose, you are still required to prepare a slide and indicate such.

Program Planners/Instructional personnel have a relevant financial relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners.

Program Planners/instructional personnel have a relevant non-financial relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners.