Presenter Worksheet-Additional Speaker

CSAP Presentation Information Submission

First and Last Name *
Credentials (e.g., MS, CCC-SLP)
Email *
Phone
Brief Speaker Bio *
Upload Photo
Presentation Title *
PRESENTER DISCLOSURES 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.
Question 1: Are you in compliance with 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.
Yes, I am in compliance with these policies (Enter initials below):
Question 2: Do you have any relevant financial relationships to disclose? *
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.NoYes - Complete Financial Relationship Disclosure Section
Question 3: Do you have any relevant non-financial relationships to disclose? *
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.NoYes - Complete Non-Financial Relationship Disclosure Section
Agreement *
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.I agree
FINANCIAL RELATIONSHIP DISCLOSURE 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.
Financial relationship with (name of Company/Organization):
My Presentation will include:
Yes, I will be referencing where I workYes, I will be referencing actual case studies from my place of employmentYes, I will be discussing a specific product and/or drug my place of employment sells
Product/Drug Name:
Will mention other similar products in your presentation?
YesNo
What was received? (Check all that apply)
SalaryConsulting feeIntellectual property rightsSpeaking feeRoyaltyHonorariaTravel SupportHold patent on equipmentIn kindGrantsOwnership interest (e.g., stocks, stock options or other ownership interest excluding diversified mutual funds)GiftOther
If Grants or Other were noted above, please describe
For what role? (Check all that apply)
Employment (Select only if referencing your place of work in your presentation)Management positionTeaching and speakingBoard membershipOwnershipConsultingMembership on advisory committee or review panelsIndependent contractor (including contracted research)Other activities
If Other was select above, please describe
NON-FINANCIAL RELATIONSHIP DISCLOSURE 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.
Non-financial relationship with (name of Company/Organization/Institution):
What is the nature of the non-financial relationship?
I have a family member or child that is affected by the topic of my presentationPersonal, please describeProfessional, please describePolitical, please describeInstitutional, please describeReligious, please describePersonal interest, please describeBias, please describeOther relationship, please describe
Please describe any of the relationships noted above
For what role?
Volunteer employmentVolunteer teaching and speakingBoard membershipVolunteer consultingVolunteer membership on advisory committee or review panelsOther volunteer activities
If Other was selected above, please describe
If you have any additional comments about your presentation or disclosures please provide them here.

CSAP Presentation Information Submission

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