×
Home
About
Board of Directors
President's Message 2024
CAA News
Education
2025 CAA Annual Conference
Membership
Membership Benefits
Join
Renew Membership
Volunteer Opportunities
DEI Statement
Advocacy
Current Legislation
Let Your Voice Be Heard!
Resources
Consumer Resources
Meetings & Events 2024
Billing Resources
Licensing
Mentorship Program
Students
Student Academy of Audiology
Find a Mentor
Student Scholarships
Contact
Member Login
Search
×
Log in to Member Area
Forgot Password?
About
Board of Directors
President's Message 2024
CAA News
Education
2025 CAA Annual Conference
Membership
Membership Benefits
Join
Renew Membership
Volunteer Opportunities
DEI Statement
Advocacy
Current Legislation
Let Your Voice Be Heard!
Resources
Consumer Resources
Meetings & Events 2024
Billing Resources
Licensing
Mentorship Program
Students
Student Academy of Audiology
Find a Mentor
Student Scholarships
Contact
Login
Mobile menu
CAA 2024 Relationship Disclosure Form
Program Planner/Instructional Personnel Relationship Disclosure Form
In compliance with American Speech-Language Hearing Association’s Continuing Education Board’s Requirements, the SJSU 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, SJSU 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.
*
- Required Field
First Name *
Last Name *
Email *
Presentation Title
*
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.
Please initial below to confirm compliance with these policies:
*
Relevant Financial Relationships
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.
Do you have relevant financial relationships to disclose?
Please select 'Yes' or 'No' below.
No, I do not have
relevant financial relationships
to disclose.
Yes, I do have
relevant financial relationships
to disclose.
Please complete the information regarding
each
of your relevant financial relationships.
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.
This form provides space to disclose up to three (3) relevant financial relationships. If you need to disclose additional relevant financial relationships, please email
info@caaud.org
.
Planner/Presenter Name:
Date form completed:
1. Financial Relationship with (name of Company/Organization/Institution):
What was received?
Select all that apply
Salary
Consulting Fee
Intellectual property rights
Speaking fee
Royalty
Honoraria
Hold patent on equipment
In kind
Grants
Ownership interest (e.g., stocks, stock options, or other ownership interest excluding diversified mutual funds)
Other financial benefit (please describe below)
If you selected "Other financial benefit", please describe below.
For what role?
Select all that apply
Employment
Management position
Teaching and speaking
Board membership
Ownership
Consulting
Membership on advisory committee or review panels
Independant contractor (including contracted research)
Other activities (please describe below)
If you selected "Other activities", please describe below.
2. Financial Relationship with (name of Company/Organization/Institution):
What was received?
Select all that apply
Salary
Consulting Fee
Intellectual property rights
Speaking fee
Royalty
Honoraria
Hold patent on equipment
In kind
Grants
Gift
Ownership interest (e.g., stocks, stock options, or other ownership interest excluding diversified mutual funds)
Other financial benefit (please describe below)
If you selected "Other financial benefit", please describe below.
For what role?
Select all that apply
Employment
Management position
Teaching and speaking
Board membership
Ownership
Consulting
Membership on advisory committee or review panels
Independant contractor (including contracted research)
Other activities (please describe below)
If you selected "Other activities", please describe below.
3. Financial Relationship with (name of Company/Organization/Institution):
What was received?
Select all that apply
Salary
Consulting fee
Intellectual property rights
Speaking fee
Royalty
Honoraria
Hold patent on equipment
In kind
Grants
Gift
Ownership interest (e.g., stocks, stock options, or other ownership interest excluding diversified mutual funds)
Other financial benefit (please describe below)
If you selected "Other financial benefit", please describe below.
For what role?
Select all that apply
Employment
Management position
Teaching and speaking
Board membership
Ownership
Consulting
Membership on advisory committee or review panels
Independant contractor (including contracted research)
Other activities (please describe below)
If you selected "Other activities", please describe below.
Relevant Non-financial Relationships
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 to disclose?
Please select "Yes" or "No" below.
No, I do not have a
relevant non-financial relationship
to disclose?
Yes, I do have a
relevant non-financial relationship
to disclose.
Please complete the information regarding
each
of your relevant non-financial relationships.
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.
This form provides space to disclose up to three (3) relevant non-financial relationships. If you need to disclose additional relevant non-financial relationships, please email
info@caaud.org
.
Planner/Presenter Name:
Date form completed:
1. Non-financial relationship with (name of Company/Organization/Institution):
What is the nature of the non-financial relationship?
Select all that apply
Personal, please describe below
Professional, please describe below
Political, please describe below
Institutional, please describe below
Religious, please describe below
Personal interest, please describe below
Bias, please describe below
Other relationship, please describe below
Please describe the nature of the non-financial relationship below.
For what role?
Select all that apply
Volunteer employment
Volunteer teaching and speaking
Board membership
Volunteer consulting
Volunteer membership on advisory committee or review panels
Other volunteer activities (please describe below)
If you selected "Other volunteer activities", please describe below.
2. Non-financial relationship (name of Company/Organization/Institution):
What is the nature of the non-financial relationship?
Select all that apply
Personal, please describe below
Professional, please describe below
Political, please describe below
Institutional, please describe below
Religious, please describe below
Personal interest, please describe below
Bias, please describe below
Other relationship, please describe below
Please describe the nature of the non-financial relationship below.
For what role?
-- No Selection --
Volunteer employment
Volunteer teaching and speaking
Board membership
Volunteer consulting
Volunteer membership on advisory committee or review panels
Other volunteer activities (please describe below)
Choose 1
If you selected "Other volunteer activities", please describe below.
3. Non-financial relationship with (name of Company/Organization/Institution):
What was the nature of the non-financial relationship?
Select all that apply
Personal, please describe below
Professional, please describe below
Political, please describe below
Institutional, please describe below
Religious, please describe below
Personal interest, please describe below
Bias, please describe below
Other relationship, please describe below
Please describe the nature of the non-financial relationship below.
For what role?
-- No Selection --
Volunteer employment
Volunteer teaching and speaking
Board membership
Volunteer consulting
Other volunteer activities (please describe below)
Choose 1
If you selected "Other volunteer activities", please describe below.
I attest that the information in this disclosure is accurate at the time of completion of this document, and I agree to notify SJSU of any changes to this information between now and the presentation.
I understand that entering my full name below serves as my electronic signature and confirms acceptance of the statement above.
Electronic Signature
Please type your first and last name
*
Date
*
Submitting Form... (Please do not close your browser)
Saving Form... (Please do not close your browser)