KSHA Program Planner/Instructional Personnel Relationship Disclosure Form
***ALL individuals who will be presenting (either 90-minute presentation or poster session) at the KSHA conference must fill this form out before the session will be considered to inclusion in the conference.

In compliance with American Speech-Language Hearing Association’s Continuing Education Board’s Requirements, the Kansas 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.

Based on the information provided, the KSHA CE Administrator 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.

Email address *
Your name *
Your answer
Title of presentation/poster *
Your answer
HIPAA Requirements
To comply with the Health Insurance Portability and Accountability Act (HIPPA), we ask that all program planners and instructional personnel insure the primacy of their patients/clients by refraining from using names, photographs, or other patient/client identifiers in course materials with out the patient’s/client’s knowledge and written authorization.
Type your initials here to indicate that you are in compliance with HIPAA. *
Your answer
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