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Glasgow, MT 59230

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ProgramPlannerRelationshipDisclosureForm

IncompliancewithAmericanSpeech-Language HearingAssociation’sContinuingEducationBoard’sRequirements,the Montana Speech–LanguageHearingAssociation(MSHA)requiresprogramplannersand instructional personnelto discloseinformationregardinganyrelevantfinancialandnon-financialrelationshipsrelatedto coursecontentpriorto andduringcourse planning.

Based ontheinformationprovided,MSHA willengage the programplanner/instructionalpersonnelin aguidedinterviewprocessthatseeks to understand howtherelevantfinancialor nonfinancial relationshipmayinfluencethecontentofthecourse.

PresenterName:

PresentationTitle:

Employedby:

Tocomplywith theHealthInsurancePortabilityand AccountabilityAct (HIPAA),weaskthatallprogramplannersand instructional personnelinsurethe privacyoftheirpatients/clients byrefrainingfromusingnames,photographs,or otherpatient/clientidentifiersin coursematerialswithoutthe patient’s/client’sknowledge and writtenauthorization.

Iwill complywiththesepolicies: (INITIALHERE)

Relevantfinancialrelationshipsarethoserelationships in whichtheindividualbenefitsbyreceivinga salary,royalty,intellectualpropertyrights,gift,speakingfee,consultingfee,honoraria,ownershipinterest (e.g.,stocks,stockoptions, orotherownershipinterest,excludingdiversifiedmutualfunds), orotherfinancialbenefit.Financialrelationships canalsoinclude“contractedresearch”wheretheinstitutiongetsthegrantand managesthefunds andtheindividualistheprincipalornamedinvestigator onthe grant.

Doyouhave relevant financialrelationshipsto disclose? No Yes Ifyes,completepage 2

Relevantnon-financialrelationshipsarethoserelationshipsthatmightbias anindividualincludinganypersonal,professional,political,institutional,religiousorotherrelationship.Mayalsoincludepersonalinterestorculturalbias.

Doyouhave relevant non-financialrelationshipsto disclose? No Yes Ifyes,completepage 3

Iattestthattheinformationin thisdisclosureisaccurate atthetime ofcompletionand Iagree to notifyMSHAof anychanges tothisinformationbetweennow and thepresentation.Typing your legal name serves as your electronic signature.

SignatureDate

FinancialRelationshipDisclosure Form

Copythis pageasmany timesas you needto completeinformationregardingeach of yourrelevantfinancialrelationships.Presentershave arelevantfinancialrelationshipifthatrelationshipcouldinfluencetheinformationpresentedinthecourseand could be perceivedas aconflictofinterestbylearners.

Presenter Name:

Financialrelationship(s)with(companyororganization):

Dateformcompleted:

Whatwasreceived?(Checkallthatapply)

Salary / Inkind
Consulting fee / Grants
Intellectualpropertyrights / Gift
Speakingfee / Ownershipinterest(e.g.,stocks,
Royalty / Stockoptions orotherownership
Honoraria / Interest excludingdiversified
Holdpatentonequipment / Mutualfunds
Otherfinancialbenefit(pleasedescribe):

Forwhat role?(Checkallthatapply)

Employment / Ownership
Managementposition / Consulting
Teachingand speaking / Membership on advisorycommittee orreviewpanels
Board membership / Independentcontractor(includingcontractedresearch)
Otheractivities (pleasedescribe):

Non-FinancialRelationshipDisclosure Form

Copy this page as many times as you need to complete information regarding each of your relevant

non–financial relationships. Presenters 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.

Presenter Name:

Financialrelationship(s)with(company ororganization):

Dateformcompleted:

Whatis thenatureofthenon–financialrelationship?(Checkallthatapply)

Personal,pleasedescribe:

Professional,pleasedescribe:

Political,pleasedescribe:

Institutional,pleasedescribe:

Religious,pleasedescribe:

Personalinterest,pleasedescribe:

Bias,pleasedescribe:

Otherrelationship,pleasedescribe:

Forwhat role?(Checkallthatapply)

Volunteeremployment

Volunteerteachingand speaking

Board membership

Volunteerconsulting

Volunteermembershipon advisorycommitteeorreview panels

Other volunteer activities (pleasedescribe):