Print Page   |   Contact Us   |   Sign In   |   Register
CEU Activity Forms
Share |

WVSHA Continuing Education Activity Worksheet

Return Completed Form To:

Helan Turner

Continuing Education Administrator

WVSHA

590 Lower Timber Ridge Road

Seneca Rocks, WV  26884

helan@spruceknob.net

 


 

 Click Here to Download & Print Form 

 


 

        

 

 

 

 

 

IMPORTANT:

All cooperative offerings must be submitted to the WVSHA Executive Board for approval.  All potential cooperative offerings must be submitted and approved by the CE administrator prior to presentation to the executive board. Cooperative offerings will not be sent to the executive board for approval until all the necessary information has been received and approved by the CE administrator.  A completed CE worksheet must be received by the CE administrator within the designated timeline prior to the start of the activity.  In addition WVSHA now charges a fee payable to WVSHA, in addition to the fee charged by ASHA.  Payment to ASHA can be made by credit card or check.  At this time, WVSHA only accepts checks for payment. Payment to WVSHA and ASHA must be made separately.

 

Timelines and fees for submission to the Continuing Education Administrator:

120 days prior to start of activity:  $500.00

90 days prior to start of activity:  $750.00

60 days prior to start of activity:  $1000.00

These fees are in addition to the $325.00 fee paid to ASHA. ASHA charges $325 for a cooperative offering and $50 for any subsequent offering of the same course content

 

 

WVSHA will process CEUs for active members of WVSHA at no charge. Those who are not active WVSHA members will be charged $75.00 per cooperative offering attended.  Fees are to be collected by the sponsoring entity and paid as a lump sum to WVSHA prior to the start of the activity. Potential attendees of the activity can check their membership status through the WVSHA web site www.wvsha.org.  Participants must be active members of WVSHA prior to the start of the activity to have the $75.00 fee waived.

WVSHA membership is $55.00 per year for Professional members and is available at WVSHA.org

 

Please note: All activities that offer 1.0 or more CUEs (10 or more hours) must be submitted 120 days prior to start of activity.  They will not be accepted less than 120 days prior to the start of the activity.

Please provide the following information:

(Please complete and return PDF document -- CLICK HERE)

1.  Activity Title

2.  Activity Location 

3.  Activity Description

4.  Starting Date 

5.  Completion Date 

6.  Contact Person/Address/Telephone/Email

7.  Registration Fee

8.  Speaker(s) Resume/Credentials (attach on additional sheets)

9. ASHA requires that learners must be informed of the instructional personnel’s relevant financial and non financial relationship in any promotional materials which are available to potential registrants and at the start of the course/activity. Individuals who refuse to disclose this information will not be allowed to present and will not be allowed to have control of, or responsibility for, the planning, management, presentation, or evaluation of the course.

(1) Please complete the attached Program Planner/Instructional Personnel Relationship Disclosure for each speaker. Forms are attached.

(2) Include a speaker disclosure in your promotional materials.  Samples are attached to this WVSHA CE Worksheet.

(3) Provide WVSHA with detailed written documentation of:

·             Names of organizations that provide financial and /or in-kind support.

·             Dollar amount received from each organization.

·             Monetary value and description of in-kind support.

·             How the money and in-kind support were used.

(4) You will be contacted by the WVSHA CEA 7 days before the start of your activity to confirm if there has been a change in the financial relationship(s) of any of your speakers. 

 

Consult the WVSHA Conflict of Interest Policy or contact the CEA with any questions. 

 

10. Time Ordered Agenda:  Please include all breaks and lunch and record in the following format and attach on additional sheets.

9:00 – 10:00 Registration

10:00 – 11:00 First Session

11:00-11:15 First Break


11. Brochure or Advertisement of your activity:  The promotional material should have a time ordered agenda, speaker credentials, and the ASHA Promotional Paragraph and Logo.  A “flyer” sent by email is a promotional material. Information about the activity posted on your organization’s website is a promotional material.  There are two versions of the ASHA promotional paragraph and logo; use the one that best fits your purposes.

 

Version #1 This version works best for tri fold brochures.

     



Version #2 This version works best for web pages or flyers.

 

 

The following AHSA CEU Information Sentence must immediately follow the ASHA logo and promotional paragraph:

This course is offered for _____  ASHA CEUs (Introductory, Intermediate, Advanced, or Various level, Basic Communication Processes, Professional, or Related Area).

EXAMPLE:  This course is offered for 1.0 ASHA CEUs (Various level, Professional Area).

Please contact the Continuing Education Administrator if you are unsure about the ASHA logo, paragraph, or information sentence.


12. Learning outcomes:  Describe the skills, knowledge, and/or attitudes (learning outcomes) that participants will be able to demonstrate as a result of the activity and attach on additional sheets.  (Please contact the WVSHA CEA if you need help writing learning outcomes.)

  

13. Assessment of Learning Outcomes: Describe the methods you will use to measure or assess what participants learned during the activity (i.e. question and answer period, survey, etc.) and attach sample if applicable.

 

14. Program Evaluation: What procedure you will use for program evaluation?  Include sample form(s) if applicable.

 

15. If this activity is sponsored by any organization or agency other than WVSHA it is considered to be a cooperative offering and is subject to a cooperative offering fee charged by ASHA and fees charged by WVSHA.  Please submit payment (check or credit card) of $325.00 payable to ASHA and a check for the appropriate amount payable to WVHSA.

 

 

 

Sample Speaker Disclosures

Sample Statements to Disclose Relevant Financial Relationship(s) of the Course's Instructional Personnel

Disclosing Financial Relationship(s) in Promotional Materials

Dr. Wadelmann; Cognitive Rehabilitation After Traumatic Brain Injury, Employed by University of Malibu Health Science Center

Disclosure: Author for ABC SLP Publishers and receives royalty payments.

Disclosing financial relationship(s) at the start of a course

Spoken Announcement (could be accompanied by slide)

Good morning, my name is Dr. Wadelmann, and I am here to discuss cognitive rehabilitation after traumatic brain injury. I am the author of the text "Management of Closed Head Injury" and of the Assessment of Language Skills in Head-Injured Patients test published by ABC SLP Publishers. Many of the concepts I'm presenting today are from my book and test. I do benefit financially from royalty payments from the sale of these products.

Template for Slide

Disclosure Statement

I have a financial interest in the products or services described, reviewed, evaluated or compared in this presentation.

§  Name of organization(s) or products/services

§  Description of relationship(s) (not amount) such as ownership interest, employee, own all or part of a licensed patent or copyright, scholarship/grant , financial compensation, etc.

Written Announcement (in handouts or course materials)

Dr. Wadelmann; Cognitive Rehabilitation After Traumatic Brain Injury, Employed by University of Malibu Health Science Center

Disclosure: Author for ABC SLP Publishers and receives royalty payments.

 

 

Sample Statements to Disclose Relevant Nonfinancial Relationship(s) of the Course's Instructional Personnel

Disclosing Nonfinancial Relationship(s) in Promotional Materials

Mr. Ken Johanson; "Comparison of Augmentative Communication Devices." Employed by Speech and Hearing Clinic of Greater Baltimore.

Disclosure: Board of directors: Talking Boxes Company. Receives no compensation as member of board of directors.

Disclosing Nonfinancial Relationship(s) at the Start of a Course

Spoken Announcement (could be accompanied by slide)

Hello, I'm Ken Johanson. My presentation compares augmentative communication devices currently on the market. I sit on the board of directors of Talking Boxes Company. Talking Boxes manufactures and sells one of the devices I'll be talking about today. I don't receive any financial compensation for my role on the board.

Template for Slide

Disclosure Statement

I have a nonfinancial interest or personal interest or bias in the products or services described, reviewed, evaluated or compared in this presentation.

§  Name of organization(s) or products/services

§  Description of relationship(s) (not amount) such as ongoing relationship, in-kind support, family member works there, etc

Written Announcement (in handouts or course materials)

Mr. Ken Johanson; "Comparison of Augmentative Communication Devices." Employed by Speech and Hearing Clinic of Greater Baltimore.

Disclosure: Board of directors: Talking Boxes Company. Receives no compensation as member of board of directors

Sample Statements to Disclose that the Course's Instructional Personnel has no Relevant Financial or Nonfinancial Relationship(s)

Disclosing that there are No Relevant Financial or Nonfinancial Relationship(s) in Promotional Materials

James Booker; "Social Media and Continuing Education." Employed by Hearing Health Education.

Disclosures: No relevant financial or nonfinancial relationships to disclose.

Disclosing that there are No Relevant Financial or Nonfinancial Relationship(s) at the Start of the Course

Spoken Announcement (could be accompanied by slide)

My name is James Booker and I'm speaking on Social Media and Continuing Education. I work for Hearing Health Education. I have no relevant financial or nonfinancial relationships to disclose.

Template for Slide

Disclosure Statement

I have no financial or nonfinancial interest or related personal interest of bias in any organization whose products or services are described, reviewed, evaluated or compared in the presentation.

Written Announcement (in handouts or course materials)

James Booker; "Social Media and Continuing Education." Employed by Hearing Health Education.

Disclosures: No relevant financial or nonfinancial relationships to disclose.

mployed by Speech and Hearing Clinic of Greater Baltimore.

Disclosure: Board of directors: Talking Boxes Company. Receives no compensation as member of board of directors

Sample Statements to Disclose that the Course's Instructional Personnel has no Relevant Financial or Nonfinancial Relationship(s)

Disclosing that there are No Relevant Financial or Nonfinancial Relationship(s) in Promotional Materials

James Booker; "Social Media and Continuing Education." Employed by Hearing Health Education.

Disclosures: No relevant financial or nonfinancial relationships to disclose.

Disclosing that there are No Relevant Financial or Nonfinancial Relationship(s) at the Start of the Course

Spoken Announcement (could be accompanied by slide)

My name is James Booker and I'm speaking on Social Media and Continuing Education. I work for Hearing Health Education. I have no relevant financial or nonfinancial relationships to disclose.

Template for Slide

Disclosure Statement

I have no financial or nonfinancial interest or related personal interest of bias in any organization whose products or services are described, reviewed, evaluated or compared in the presentation.

Written Announcement (in handouts or course materials)

James Booker; "Social Media and Continuing Education." Employed by Hearing Health Education.

Disclosures: No relevant financial or nonfinancial relationships to disclose.

 

 

Program Planner/Instructional Personnel Relationship Disclosure Form

 

                  In compliance with American Speech-Language Hearing Association’s Continuing Education Board’s Requirements, WVSHA 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, WVSHA 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.

Program Planner/Instructional Personnel’s Name: ______________________________________

Course Title: 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)

 

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.

Do you have relevant financial relationships to disclose? No Yes, if yes complete page 2

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.

Do you have relevant non-financial relationships to disclose? No Yes, if yes complete page 3

 

Financial Relationship Disclosure Form

 

      Copy this page as many times as you need to complete information regarding each of your relevant financial relationships. 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.

 

Planner/Presenter name: _________________________________________________________

Financial relationship with (name of Company/Organization): ___________________________

Date form completed: _____________________

 

What was received? (Check all that apply)

___           Salary

___           Consulting fee

___           Intellectual property rights

___           Speaking fee

___           Royalty

___           Honoraria

___           Hold patent on equipment

____        In kind

____        Grants

____        Gift

___           Ownership interest (e.g., stocks, stock options or other ownership interest excluding diversified mutual funds)

___      Other financial benefit (please describe):

 

For what role? (Check all that apply)

___      Employment

___      Management position

___      Teaching and speaking

___      Board membership

___      Ownership

___      Consulting

___      Membership on advisory committee or review panels

___      Independent contractor (including contracted research)

___      Other activities (please describe):

  

Non-Financial Relationship Disclosure Form

Copy this page as many times as you need to complete information regarding each of your relevant non-financial relationships. Program Planners/instructional personnel have 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.

Planner/Presenter name: ____________________________________________

Non-financial relationship with (name of Company/Organization/Institution): _______________________________________________________________

Date form completed: _________________________________

 

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

Personal, please describe:

Professional, please describe:

Political, please describe:

Institutional, please describe:

Religious, please describe:

Personal interest, please describe:

Bias, please describe:

Other relationship, please describe:

 

For what role?

Volunteer employment

Volunteer teaching and speaking

Board membership

Volunteer consulting

Volunteer membership on advisory committee or review panels

Other volunteer activities (please describe):

 

 

IMPORTANT

 Please be aware that:

 

1.         All relevant forms (sign in sheets, attendance verification forms, ASHA attendance verification forms i.e. “scantrons”) must be received by the Continuing Education Administrator (CEA), within three weeks (21 days) of the completion of the activity.

 

2.         Any information mailed to the Continuing Education Administrator via the US Postal Service must be sent certified return receipt OR it is your responsibility to confirm that it was received by the CEA.  ASHA attendance verification forms (scantrons) must be mailed unless you contact the Continuing Education Administrator to make other arrangements.  Please remember not to fold, bend, or staple the scanton forms.

 

3.         You are encouraged to email as much information to the CEA as possible, but it is your responsibility to ensure that your email was received.  It is suggested you request a return receipt on your email. 

 

4.         By submitting this Continuing Education Work Sheet you are acknowledging that you are aware that if you fail to comply with any time lines, your organization is responsible for any late fees charged by ASHA and the participants may not receive credit for any CEUs they earned.  The minimum late fee charged by ASHA is $200.  Any late fees incurred by your organization could be substantially more.

5.       Failure to comply with set time lines may result in your organization being placed on probation with regards to continuing education opportunities with WVSHA.  

Search
Sign In
Sign In securely