Instructions for Completing the Conflict of Interest Disclosure Form

Instructions for Completing the Conflict of Interest Disclosure Form

for AMA Council and Committee Members/Candidates

Before completing the attached disclosure form, please review carefully the AMA's Conflict of Interest Policy. Please also review the related Conflict of Interest Principles-Councils, Committees, and Task Forces, which provide explanatory text and examples of the Policy in specific situations.

In accordance with action by the AMA House of Delegates at I-13, disclosure forms completed by candidates for positions elected by the House of Delegates will be posted on the "members only" portion of the AMA website in advance of the election.

If you are seeking re-election, please update your previously completed disclosure form (contact to request a copy if needed). If you are not an incumbent seeking re-election, please complete the blank disclosure form Word document, affix your electronic signature and return as an attachment to an email to . If you prefer or are not able to affix your electronic signature, complete the blank but unsigned disclosure form Word document, along with a manually signed disclosure form, and return both as attachments [the manually signed form attached as a pdf] to an email to .

As you update/complete the disclosure form, please also consider if there are pending matters, or matters which you anticipate may occur during your term of office, which could, in your view, reasonably be anticipated to adversely impact your ability to discharge fully the duties you are seeking--without embarrassment to yourself or to the AMA.

If you have questions about the AMA’s Conflict of Interest Policy, the AMA's General Counsel is available to provide guidance (). The General Counsel is also available to discuss any other matters you may wish to raise.

Attachment

Council and Committee Members

Disclosure of Affiliations

and

Statement of Compliance with the

American Medical Association

Conflict of Interest Policy

The American Medical Association's Conflict of Interest Policy requires each Council and Committee Member to disclose annually his or her affiliations and to execute a statement confirming that, to his or her knowledge, the Member has complied with the Conflict of Interest Policy.

Disclosure of a Member's affiliations is intended to assist the AMA in resolving conflicts of interest. A Member's affiliation with another organization does not necessarily mean that a conflict of interest exists or that the affiliation would unduly influence the Member.

A listing of all Council and Committee Members' affiliations will be distributed to all Members of their Council or Committee.

Affiliations

Please complete each question to the best of your knowledge. You may list your answers directly on this form or you may provide your answers on a separate sheet of paper. If you attach your C.V., please indicate on this form to which questions your C.V. responds, and please answer all questions not addressed by your C.V.

If you become affiliated with another organization or cease an affiliation within the next 12 months, please provide information on such affiliation to your Council Secretary.

The following terms used in this statement have the following meanings:

"AMA" means the American Medical Association and its subsidiaries and affiliates.

"Material financial interest" means:

a financial ownership interest of 5% or more, or

a financial ownership interest which contributes materially to your income, or

a position as proprietor, director, managing partner or key employee.

“Immediate family member” shall mean spouse, domestic partner, parent or child.

“Extended family member” shall mean spouse, domestic partner, parent, mother-in-law, father-in-law, child, spouse of child, grandchild, brother, sister, or spouse or child of a brother or sister. Guidelines relating to interests held by an immediate family member or extended family member shall apply to the extent such interests are known to the Member.

Your responses will be reviewed with regard to your obligations to serve on an AMA Council or Committee and to fairly evaluate matters that come before your Council or Committee.

1.What is your current principal occupation? Please be specific/provide detail.

2. Do you or an extended family member hold or plan to hold a material financial interest in any business which furnishes goods or services, or is seeking to furnish goods or services, to the AMA?

No:

Yes:

If yes, please list the name of each business and the type of goods or services involved.

3.Have you or any extended family member asserted or filed, or intend to assert, a lawsuit, legal complaint, personal claim for damages or formal grievance against the AMA?

No:

Yes:

If yes, please describe the nature and status of the legal action.

4.Do you or any immediate family member hold or plan to hold a material financial interest in any health care business or health care facility, including a private medical practice?

No:

Yes:

If yes, please list the name of each business or facility and provide a brief description of the type of business or facility.

5.Are you, or any immediate family member, or do you, or any immediate family member, anticipate becoming within the next 12 months, a Trustee, Director, Officer, Council or Committee member, employee or consultant of any health care organization or health-related professional society?

No:

Yes:

If yes, please list the name of each organization, position held, and term of position. If the organization is not a nationally known organization, please provide a brief description of the organization.

6.Are you, or do you anticipate becoming within the next 12 months, a Trustee, Director, Officer, Council or Committee member, employee or consultant of any non-health care type of organization or society?

No:

Yes:

7.Do you hold, or do you anticipate holding within the next 12 months, any faculty appointments?

No:

Yes:

If yes, please list the name of each institution, position held, and term of appointment.

8.Are you involved in, or do you anticipate becoming involved in, public representation and advocacy, including lobbying, on behalf of any organization?

No:

Yes:

If yes, please list the name of each organization and describe the nature of the activities you are or will be involved in.

9.Do you hold or intend to seek within the next 12 months any political office (elected or appointed)?

No:

Yes:

If yes, please list each political office.

10.Are you involved in, or do you intend to become involved in within the next 12 months, any other significant political activities (excluding voting and political contributions)?

No:

Yes:

If yes, please describe your political activities.

11.Are you aware of any activity of any of your family members which may conflict with the policies or activities of your Council/ Committee?

No:

Yes:

If yes, list the family member involved and the nature of the activity.

12.Are you involved in any other personal relationship, activity or interest which may raise a conflict of interest or impair your objectivity on any policies or issues of your Council/Committee?

No:

Yes:

If yes, please describe each relationship, activity or interest.

Affirmation

In consideration of my participation on the Council/Committee, I assign to the American Medical Association all rights, including copyright in any work products including but not limited to any publications or tools created in connection with my participation on the Council/Committee.

I understand that I am expected to comply with the Conflict of Interest Policy of the American Medical Association. To my knowledge and belief, I am in compliance with the Conflict of Interest Policy and have disclosed my affiliations. I understand that I have continuing responsibility to comply with the Conflict of Interest Policy, and I will promptly disclose any affiliations required to be disclosed under the Policy.

Printed Name:

Signature:

Council or Committee Name:

Date:

Updated May 21, 2015