ASHA & NCSHLA

Instructional Personnel Relationship Disclosure

In compliance with American Speech-Language Hearing Associations Continuing Education Boards Requirements, the North Carolina Speech, Hearing and Language Association, Inc. (NCSHLA) requires presenters 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, NCSHLA 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.

Complete the form below, or complete and return the downloadable form to NCSHLA offices.


*Required for follow-up correspondence.

HIPAA Requirements
I am in compliance with these policies: (Initial Required)
Relevant Financial Relationships

Financial Relationship Disclosure Form
Presenter has 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.

Relevant Non-Financial Relationships

Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. May also include personal interest or cultural bias.

Non-Financial Relationship Disclosure Form
Presenter has 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.

Describe Personal Interest
Describe Professional Interest
Describe Political Interest
Describe Institutional Interest
Describe Religious Interest
Describe Personal Interest
Describe Bias Interest
Describe Other Non-Financial Interest

I attest that the information in this disclosure is accurate at the time of completion and I agree to notify NCSHLA of any changes to this information between now and the presentation.

Please enter your full name.

(MM/DD/YYYY)
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