2018 KSHA Program Planner/Instructional Personnel Relationship Disclosure Form (Responses)
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TimestampEmail AddressYour nameTitle of presentation/poster
Type your initials here to indicate that you are in compliance with HIPAA.
Do you have any relevant financial relationships to disclose?
I have a financial relationship with (name of company/organization):
What was received? (check all that apply)
For what role? (Check all that apply)
Do you have any non-financial relationships to disclose?
I have a non-financial relationship with: (name of company/organization)
What is the nature of the non-financial relationship? (check all that apply)
Description of non-financial relationship
For what role? (check all that apply)
Description of other activities
If you have additional financial or non-financial disclosures with other companies/organizations, please describe them here:
I attest that the information in this disclosure is accurate at the time of completion and I agree to notify KSHA of any changes to this information between now and the presentation. (Type your name to indicate your signature)
Date signed
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3/15/2018 8:00:41r.pogash@oticon.comRandi R. PogashThe Aging Brain - Considerations for Hearing Loss and AmplificationRRPNo.No.Randi R Pogash3/15/2018
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4/15/2018 17:40:00alexan14@purdue.eduJoshua Alexander
Adaptive Nonlinear Frequency Compression Reveals Mechanisms for Perception of Frequency-Lowered Speech
JMAYes.
Signia, Oticon, Phonak, Starkey, and ReSound hearing aid companies; Creare, LLC
Grants, Consulting fee, Honoraria, Hold on patent on equipment
Teaching and speaking, Consulting
No.Joshua Alexander4/15/2018
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4/15/2018 17:43:29alexan14@purdue.eduJoshua AlexanderWide Dynamic Range Compression: The Good, The Bad, and The UglyJMAYes.
Signia, Oticon, Phonak, Starkey, and ReSound hearing aid companies; Creare, LLC
Grants, Consulting fee, Honoraria, Hold on patent on equipment
Teaching and speaking, Consulting
No.Joshua Alexander4/15/2018
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4/21/2018 8:24:32
cari@cariebertseminars.com
Cari EbertSensory for the SLPCEYes.Speech CornerRoyalty
They published and sell a book that I co-authored
No.Cari Ebert4/21/2018
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4/29/2018 19:37:54
sneumann@heartsforhearing.org
Sara NeumannProcesses Promoting Quality Pediatric Services & ProgramsSNYes.Cochlear Corporation
Grants, Travel fees for conference presentation & trainings
Independent contractor (including contracted research)
No.Sara Neumann4/29/2018
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4/30/2018 10:42:48
Elizabeth.Stewart@phonak.com
Elizabeth Stewart
Teleaudiology: Bringing Engagement, Ease, and Empowerment to Service Provision
ESYes.PhonakSalaryEmploymentNo.Elizabeth Stewart4/30/2018
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5/1/2018 15:26:34
jeffrey.simmons@boystown.org
Jeffrey SimmonsAuditory Neuropathy Spectrum Disorder: What Do We Know For Sure?JLSYes.KSHAHonorariaTeaching and speakingNo.Jeffrey L. Simmons5/1/2018
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5/7/2018 13:55:09tfunk@qliomaha.comTrisha Funk
The Application of Errorless Learning Principles in Achieving Successful Daily Routines
tfNo.No.Trisha Funk5/7/2018
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5/7/2018 13:56:14
jennifer.pike@qliomaha.com
Jennifer Pike
The Application of Errorless Learning Principles in Achieving Successful Daily Routines
jpNo.No.Jennifer Pike5/7/2018
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5/11/2018 14:16:51
loni.arrese@osumc.edu
Loni Arrese
Current trends and management of head and neck cancer-induced dysphagia
LANo.No.Loni Arrese5/11/2018
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5/11/2018 16:21:00
cmba@interacoustics.com
Cammy BahnerCurrent Trends in Vestibular AssessmentCLBYes.
Interacoustics and Micromedical Technologies
SalaryEmploymentNo.Cammy Bahner5/11/2018
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5/15/2018 14:21:23trisha.self@wichita.eduTrisha Self
Autism Spectrum Disorder: Somethings New, Somethings Old, Somethings Borrowed, and a Bit about WSULightitUpBlue: Assessment Practices
TLSNo.No.Trisha L. Self5/15/2018
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5/15/2018 14:29:35trisha.self@wichita.eduTrisha Self
Autism Spectrum Disorder: Somethings New, Somethings Old, Somethings Borrowed, and a Bit about WSULightitUpBlue: Intervention Practices
TLSNo.No.Trisha L. Self5/15/2018
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5/21/2018 10:46:00
teresa.graham@wichita.edu
Terre Graham, PhD,Supporting Preschool Children with Challenging BehaviorsTGNo.No.Terre Graham5/21/2018
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6/11/2018 19:27:10
gretchenstorm@gmail.com
Gretchen Valieta Storm
AAC EvaluationGSNo.No.Gretchen Storm6/11/2018
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6/11/2018 19:31:12
gretchenstorm@gmail.com
Gretchen StormAAC ImplementationGSYes.
Speech Therapy of the Rocky Mountains, LLC
I will be discussing a Teachers Pay Teachers page and a book which I sell as strategies for implementation.
Teaching and speaking, Consulting
Yes.
Speech Therapy of the Rocky Mountains, LLC
Professional, please describe below
I will be discussing a personal website I own and manage which houses many free implementation resources.
Gretchen Storm6/11/2018
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6/13/2018 13:26:44hlyons@cox.netHolly LyonsSpeech and Language Treatment of the Bilingual ChildHLYes.
Bilingual Speech Therapy of Kansas, LLC
potential referrals to our clinic
Teaching and speakingYes.
Professional, please describe below
I have a professional interest in the area of bilingualism and speech and language disorders (identification and treatment).
Other volunteer activities (please describe)
Bilingual Speech Therapy of Kansas, LLC, provides a space and support for a Parent Support Group for parents of children who have language disorders who are bilingual.
Holly Lyons6/13/2018
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6/13/2018 15:36:13
dawn.franz@usd373.org
Dawn FranzCoaching for Communication and Feeding of Young ChildrenDFNo.No.Dawn Franz6/15/2018
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6/15/2018 21:41:20carlos@bstkansas.comCarlos Montes Aviles"Treating the Bilingual Child: Challenges and Opportunities." CMAYes.KSHAHonorariaPresenterNo.Carlos Montes-Aviles6/15/2018
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6/26/2018 16:42:10
sue.t.hale@vanderbilt.edu
Sue HaleYour Future Professional PartnershipsSHYes.
Kansas Speech-Language-Hearing Association
HonorariaTeaching and speakingNo.Sue T. Hale6/26/2018
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6/26/2018 16:47:05
sue.t.hale@vanderbilt.edu
Sue HaleSupervision in the Real WorldSHYes.
Kansas Speech-Language-Hearing Association
HonorariaTeaching and speakingNo.Sue T. Hale6/26/2018
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6/30/2018 10:58:06
stacie.clarkson@greenbush.org
Stacie ClarksonA Journey from Traditional to Tele Therapy ModelSCNo.No.Stacie Clarkson6/30/2018
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7/15/2018 21:53:59
renee.kinder@encorerehabilitation.com
Renee Kinder
“Quality Documentation and Regulatory Standards: What you need to know” (1.5 hours)
RKNo.No.Renee Kinder7/15/2018
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7/31/2018 9:54:51
lesleyt@mindsmatterllc.com
Lesley Tilley
Cognitive-Communication Therapy in TBI population: Functional Based Intervention and Goal Planning
LTNo.No.Lesley Tilley7/31/2018
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9/13/2018 20:41:40
york.jonathan@outlook.com
Jonathan York
The OTC Hearing Aid bill: Its Implications and Effect on Audiology Private Practice
JYNo.No.Jonathan York9/13/2018
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2/21/2018 10:40:23kpedersen@ku.eduKris Pedersen
Understanding the Language Assessment Program for Children who are Deaf/Hard of Hearing
KPNo.No.Kristin Pedersen2/21/2018
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2/21/2018 10:52:00eschuweiler@kssdb.orgErin Schuweiler
Understanding the Language Assessment Program for Children who are Deaf/Hard of Hearing
EVSNo.No.Erin Schuweiler2/21/2018
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2/25/2018 11:27:47ewslp1@comcast.netEllen S WeberCreating Individualized Therapy AppsEWYes.Consulting fee, Royalty
Consulting, I have used this company's app to create apps which are available for sale in their marketplace
Yes.Tiny Spark Inc
Professional, please describe below
I have served as guest blogger and beta tester for this app company in the past, for which I was not compensated, as I have with several other app companies
Other volunteer activities (please describe)
see aboveNAEllen S. Weber2/25/2018
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3/11/2018 9:36:25
Hallie@speechtimefun.com
Hallie ShermanSpeech-Language PathologistHSYes.Speech Time Fun, Inc.
Intellectual property rights, Honoraria
Teaching and speakingNo.Hallie Sherman3/11/2018
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3/13/2018 14:20:26
c_brackey@mail.fhsu.edu
Courtney Brackey
Elementary School Teachers' Perceptions: The Referral Process and Collaboration with Speech-Language Pathologists
CBNo.No.Courtney Brackey3/13/2018
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