Presenter Disclosure Form

Authors/Presenters

Disclosure Statement

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. For all financial relationships, indicate the institution providing the funding for salary, royalties, grants, etc.
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.

First Name *

Last Name *

Email *

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 above):

Does this presenter have any relevant financial relationships to disclose: *

Yes

If yes, please provide an explanation of the disclosure: *

Does this presenter have any relevant non-financial relationships to disclose: *

Yes

If yes, please provide an explanation of the disclosure: *

Grants/Research Funding *

List all applicable grants and research funding.

Presentations About Products or Services

Courses providing information about a product or service are to use the following guidelines:

Must provide information in a scholarly manner regarding theoretical aspects related to the product or service and/or the details of operation.
Must disclose prior to the course that there will be limited or no information provided about similar products or services.

Will this presentation focus on information about a product or services: *

Yes

If the presentation will provide information about a product or service, please provide the name of the product/service: *

Will the presentation contain information solely on the product/service noted above: *

Yes

Will similar products/services be introduced in the presentation: *

Yes

Disclosure to Attendees: All presenters will be required to provide appropriate disclosures prior to the start of their presentation.

Agreement *

I agree

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.

Presenter Disclosure Form

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