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. 

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. 
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.
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.
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.