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: Jessica Silva, M.A., CCC-SLP
Financial relationship with Maryland Speech-Language-Hearing Association
Date form completed: 10/5/15
Relevant Financial Relationship Disclosures:
o I am employed by Baltimore City Public Schools, in the position of Speech Language Pathologist.
My responsibilities include: (please indicate) _____management, _X_teaching and speaking,
__X_ services to clients, __X__consulting, _X__ mentoring.
o I currently _____serve on the board, or _____am a member of an advisory committee or review
panel, for (company)__________________________ taking part in decisions regarding policy
and purchases.
o I own or partially own _________________________________________, for a company that
_____publishes relevant materials or _________manufactures equipment that is relevant to my
topic in this presentation, for which I receive royalties, payment or stock options, or which
________holds the patent on specified equipment.
o I have published (#)_____books, _____articles, _______manuals, _____materials for which I
receive _____royalties or other financial benefits. (Please name relevant materials separately,
indicate whether they will be ___________referred to in your presentation, or ___________will
be the sole materials or products discussed.)
o I am currently _____an independent contractor, ______involved in contracted research under a
grant for _______________________ (organization receiving the grant) from
(grantor)___________________.
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:________________________________________________________________________
Relevant Non-Financial Relationship Disclosures:
o
Personal: ______I have a personal friendship with someone in the company whose products I
will be discussing;_______ I have a family member or friend with a disorder that I am covering in
the course.
o
Professional: l_____ I am a member of an association or group (Group
name:__________________), and I will be talking about that group's services in the
presentation. _____I have a professional bias about a way to deliver a particular service.
o
Political: _____ I have a political bias about a topic (e.g., health care reform), and toward
supporting a particular party's position on this issue.
o
Institutional: _____ I am affiliated with an institution or organization (name of
organization______________________________) and I serve on a committee or board of that
organization or perform some non-financial service). _____I am a member of that organization
and/or gives money to its causes.
o
Religious: _____ I have a bias that is based on religious tenets. (e.g., a bias toward service
delivery at end of life on the basis of religious beliefs).
Pages 3-5 must be completed and signed for each speaker in your presentation.
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.
I am in compliance with these policies :_____________(INITIAL HERE)
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: Jessica Silva, M.A. CCC-SLP
Course Title: Prevention and Intervention for Early Learners: PreK and Kindergarten
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:
Jessica Silva M.A. CCC-SLP
Date
October 5, 2015
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: Lauren Burrows, M.A. CCC-SLP
Financial relationship with Maryland Speech-Language-Hearing Association
Date form completed: 10/4/15
Relevant Financial Relationship Disclosures:

I am employed by Baltimore City Public Schools, in the position of Speech Language
Pathologist. My responsibilities include: (please indicate) _____management, _____teaching
and speaking, ____X___services to clients, __X__consulting.

I currently _____serve on the board, or _____am a member of an advisory committee or review
panel, for (company)__________________________ taking part in decisions regarding policy
and purchases.

I own or partially own _________________________________________, for a company that
_____publishes relevant materials or _________manufactures equipment that is relevant to my
topic in this presentation, for which I receive royalties, payment or stock options, or which
________holds the patent on specified equipment.

I have published (#)_____books, _____articles, _______manuals, _____materials for which I
receive _____royalties or other financial benefits. (Please name relevant materials separately,
indicate whether they will be ___________referred to in your presentation, or ___________will
be the sole materials or products discussed.)

I am currently _____an independent contractor, ______involved in contracted research under a
grant for _______________________ (organization receiving the grant) from
(grantor)___________________.

_____I am receiving a speaking fee/honorarium from MSHA for this presentation.

_____My other activities or financial benefits that are relevant to this presentation
include:________________________________________________________________________
Relevant Non-Financial Relationship Disclosures:

Personal: ______I have a personal friendship with someone in the company whose products I
will be discussing;_______ I have a family member or friend with a disorder that I am covering in
the course.

Professional: l_____ I am a member of an association or group (Group
name:__________________), and I will be talking about that group's services in the
presentation. _____I have a professional bias about a way to deliver a particular service.

Political: _____ I have a political bias about a topic (e.g., health care reform), and toward
supporting a particular party's position on this issue.

Institutional: _____ I am affiliated with an institution or organization (name of
organization______________________________) and I serve on a committee or board of that
organization or perform some non-financial service). _____I am a member of that organization
and/or gives money to its causes.

Religious: _____ I have a bias that is based on religious tenets. (e.g., a bias toward service
delivery at end of life on the basis of religious beliefs).
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:
_Lauren Burrows, M.A. CCC-SLP
_Prevention and Intervention for Early Learners: PreK and Kindergarten
Course Title
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:
Lauren Burrows M.A. CCC-SLP
Date
October 4, 2015