ASHA Disclosure Form - THE VOICE FOUNDATION

ASHA DISCLOSURE FORM 2025

Department of Communication Sciences and Disorders – Temple University

INSTRUCTIONAL PERSONNEL AND CO-SPONSORING ORGANIZATIONS DISCLOSURE OF RELEVANT FINANCIAL AND NON-FINANCIAL RELATIONSHIPS

In compliance with American Speech-Language Hearing Association’s Continuing Education Board’s Requirements, the Department of Communication Sciences of Temple University 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 CE coordinator or his/her designee 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.

2025 ASHA Disclosure Form

Program Planner or Instructional Personnel’s Name: (All Authors Must Complete One ASHS Form)

Name(Required)

First Last

Email(Required)

Course Title: This is the title of your presentation.(Required)

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 patients/clients knowledge and written authorization.

HIPAA(Required)

I am in compliance with these policies: (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.

Include all information regarding each of your relevant financial or non-financial relationships. Program Planners/Instructional personnel have a relevant relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners.

Do you have relevant financial relationships as defined above. If yes, complete all information below.(Required)

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 as defined above. If yes, complete all information below.(Required)

Yes

Attest to Accuracy(Required)

Yes this disclosure is accurate

By checking this box, I attest that the information in this disclosure is accurate at the time of completion and I agree to notify the CE Coordinator at Temple University’s Department of Communication Sciences and Disorders of any changes to this information between now and the presentation.

Financial Relationships

(1) Name of Commercial Interest

(2) Name of Commercial Interest

(3) Name of Commercial Interest

Detailed Financial Disclosures

Salary

Consulting Fee

Intellectual property rights

Speaking Fee

Royalty

Honoraria

Hold Patent on equipment

In Kind

Grants

Gifts

Other Ownership interest (e.g., stocks, stock options or other ownership interest excluding diversified mutual funds)

Other financial benefit. Please describe below:

Please check all that apply

Other Financial Benefit

For What Role?

Employment

Management position

Teaching and speaking

Board membership

Ownership

Consulting

Membership on advisory committee or review panels

Independent contractor (including contracted research)

Other activities (please describe):

Other Activities

Describe any other role/activity

Non-Financial Relationship

Non-Financial Relationship Disclosures

Personal, describe below

Professional, describe below

Political, describe below

Institutional, describe below

Bias, describe below

Other relationship, describe below

What is the nature of the non-financial relationship? (complete all that apply)

Other Financial Benefit

Non-financial For What Role

Volunteer employment

Volunteer teaching and speaking

Board membership

Volunteer consulting

Volunteer on advisory committee or review panels

Other volunteer activities (describe below)

Non-Financial describe role

This field is hidden when viewing the form

Section Break

Signature (Please type)(Required)

Co-Sponsoring Organization

Title of Org Rep

Date(Required)

MM slash DD slash YYYY

The Voice Foundation

Advancing Understanding of the Voice
Through Interdisciplinary Research & Education

ASHA DISCLOSURE FORM 2025

Department of Communication Sciences and Disorders – Temple University

2025 ASHA Disclosure Form

HIPAA REQUIREMENTS

Financial Relationships

Non-Financial Relationship

Section Break

JOURNAL OF VOICE

About JOV
Journal Home
JOV Annual Best Papers

DOWNLOADS

2022 Symp Program
2019 Abstracts
Programs and Abstracts

PARTNERSHIPS

Exhibitor Prospectus
Marketing
Leading Roles

ASHA DISCLOSURE FORM 2025

Department of Communication Sciences and Disorders – Temple University

2025 ASHA Disclosure Form

HIPAA REQUIREMENTS

Financial Relationships

Non-Financial Relationship

Section Break

JOURNAL OF VOICE

About JOVJournal HomeJOV Annual Best Papers

DOWNLOADS

2022 Symp Program2019 AbstractsPrograms and Abstracts

PARTNERSHIPS

Exhibitor ProspectusMarketingLeading Roles

About JOV
Journal Home
JOV Annual Best Papers

2022 Symp Program
2019 Abstracts
Programs and Abstracts

Exhibitor Prospectus
Marketing
Leading Roles