The MSHA Convention is held in April or early May each year.  Once the date and location are finalized, they will be posted on the website.
If you are interested in speaking at an upcoming Convention, please submit information here and we will be in touch.  Thank you.

Multipage

Step 1 of 3 PRESENTER(S)

Presenter 1

Presenter 2

Please note: One presenter who is collecting CEUs from each session may attend the convention at no cost.

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Step 2 of 3 PRESENTATION

(50 words, single-spaced, to be printed in the convention program)

COURSE OBJECTIVES/LEARNER OUTCOMES

(50 words or Less)

MSHA will provide an LCD projector, screen, and microphone (if needed) in your session room. Any special requests for audio speakers for your presentation must be made now to make sure we have the correct equipment ready for your session. Please note: MAC users should bring their own connection cord for the LCD projector hook up.

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Step 3 of 3 DISCLOSURE

  1. This signed form must be submitted to MSHA.
  2. If you have a disclosure that you frequently use, please upload it in your application, as well as submitting this form.
  3. You are also responsible for disclosing your financial relationships at the event where you will present, either in a slide, verbally, or in your handout.  

Thank you for your cooperation. 

 

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.

(INITIAL HERE)

Relevant financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, gift, speaking fee, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include “contracted research” where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant.

If yes complete the Financial Relationship Disclosure Form.

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.

If yes complete the Non-Financial Relationship Disclosure Form.

Financial Relationship Disclosure Form(s)

Order
Financial Relationship Disclosure Form 1

(Check all that apply)

(please describe)

(Check all that apply)

(please describe)

Non-Financial Relationship Disclosure Form(s)

Order
Non-Financial Relationship Disclosure Form 1

(name of Company/Organization/Institution)

What is the nature of the non-financial relationship? (Complete all that apply)

(Complete all that apply)

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.  

Based on the information provided, the CE Administrator or a designated Board Member will engage the program planner/instructional personnel in a guided interview process which seeks to understand how the relevant financial or nonfinancial relationship may influence the content of the course.  

 

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. 

Date *

Format: Nov 25 2017

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