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

Financial Relationships

(1) Name of Commercial Interest

(2) Name of Commercial Interest

(3) Name of Commercial Interest

Detailed Financial Disclosures

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

Hidden

Section Break

Signature (Please type)(Required)

Co-Sponsoring Organization

Title of Org Rep

Date(Required)

The Voice Foundation

Advancing Understanding of the Voice
Through Interdisciplinary Research & Education

Philadelphia, New York, Los Angeles, Cleveland, Boston, Paris, Lebanon, Brazil, China, Japan, India, Mexico