California Academy of Audiology

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.

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.

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.

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.

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.

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