Financial and Non-Financial Relationship Disclosure Form
For Program Planners and Instructional Personnel
In compliance with American Speech-Language Hearing Association’s Continuing Education Board’s Requirements, the Maryland Speech-Language-Hearing Association 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
Financial Relationship Disclosure Form
Copy this page as many times as you need to provide complete information regarding each of your relevant relationships. Please provide one for each speaker if there is more than one in your presentation. 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. Please check all areas that apply, and complete the statements for each area in both financial and non-financial relationships.
If you have a disclosure statement that you use regularly, please feel free to include it after you have checked each area. Please remember to sign and date the attestation.
Planner/Presenter name: _____Yvette McCoy, MS CCC-SLP
Financial relationship with Maryland Speech-Language-Hearing Association
Date form completed: October 7, 2015
Relevant Financial Relationship Disclosures:
o I am employed by MedStar National Rehabilitation Hospital, MedStar St. Mary’s Hospital and Owner of Speak Well Solutions, LLC in the position of Senior Speech Language Pathologist. My responsibilities include: management, teaching and speaking, services to clients, and consulting.
o I am receiving a speaking fee/honorarium from MSHA for this presentation.
o _____My other activities or financial benefits that are relevant to this presentation include Webinars for Northern Speech Services and The American Board of Swallowing and Swallowing Disorders; Co-Author of Dysphagia TherAppy by Tactus Therapy
o Relevant Non-Financial Relationship Disclosures:
o Institutional: I am affiliated with an institution or organization the Dysphagia Research Society and I serve on a committee of that organization (Website Public Relations Committee) and moderate both Twitter and Facebook accounts for the organization I am a member of that organization and/or gives money to its causes.
Pages 3-5 must be completed and signed for each speaker in your presentation.
Based on the information provided, the CE Administrator or a designated Board Member may conduct a guided interview that seeks to understand how the relevant financial or nonfinancial relationships may influence the content of the course.
Program Planner/Instructional Personnel’s Name:
Yvette McCoy, MS CCC-SLP
Course Title Putting It All Together: A comprehensive Approach To Dysphagia Management Across A Continuum of Care
I attest that the information in this disclosure is accurate at the time of completion and I agree to notify The Maryland Speech-Hearing-Language Association of any changes to this information between now and the presentation.
Signature Yvette M. McCoy Date October 7, 2015