Instructional Personnel Disclosure

LCDS #1005

Non-Disclosure Form

 

Presenter: Melissa Jakubowitz, M.A., CCC-SLP, BCS-CL (Founder & President elivenow)

Session Title: Moving Teletherapy Forward: Strategies for Effective Teletherapy and Telesupervision

Date: August 27, 2020, 5-7 pm

The Continuing Education Board requires its Providers to have a written process in place to 1) identify relevant conflicts of interest, 2) determine if the existence of those conflicts of interest disqualifies an individual from being involved in the course planning and delivery, and 3) disclose conflicts of interest to learners. Instructional personnel disclosure information must be made available to the participants prior to the course through promotional materials and before the course conveyed through written handout and/or announcement by the instructor, ASHA CE administrator, or person introducing the instructor. 

 

Please check ONE and compete the following as appropriate to potential conflicts of interest:

X      Relevant financial relationship(s)

If yes, please list the name of the organization and the type of financial relationship

President/Founder of eLiveNow, a telepractice company

 

X      Relevant nonfinancial relationship(s)

If yes, please list the name of the organization and the type of nonfinancial relationship

Member of ASHA SIG 18 Telepractice and former SIG 18 Coordinator

 

___      No relevant financial or nonfinancial relationships exist.