RENAL DIETITIANS (RPG) OF THE
ACADEMY OF NUTRITION AND DIETETICS
CONFLICT DISCLOSURE STATEMENT
FOR RPG EXPERT REVIEWERS/CONTENT ADVISORS, PRESENTERS &
ED. MATERIAL DEVELOPMENT
I, ______, acknowledge that I am being considered, or have been accepted, to perform certain services for or on behalf of Renal Dietitians of the Academy of Nutrition and Dietetics. I am being considered, or have agreed, to work with the RPG on the following:
______
(Insert service)
By signing this Statement, I acknowledge that such performance requires objectivity; credibility; the avoidance of an appearance of external influence; and, in some cases, the absence of a conflict with Academy positions or statements. I am aware of the need to satisfy such standards, and the purpose of this statement is to disclose any facts or circumstances that might create the appearance of a conflict with these standards.
(a)If the position that I intend to fill is author, reviewer, presenter, or content advisor, I hereby affirm that there is no impediment to my providing these services professionally, credibly, objectively, and without undue external influence. To the extent that I may have relationships with, or derive compensation from, companies, organizations, or enterprises that have a direct interest in the subject matter of the services I am asked to perform, I believe that those facts will not unduly influence my conclusions or performance. Nevertheless, I disclose below any companies, organizations or enterprises from which I receive compensation or with which I have an ongoing relationship.
(b)If I am being asked to act as a designated representative of the RPG/Academy, whether as author, reviewer, presenter, or content advisor,, or any other similar capacity, I understand that I owe an absolute duty of loyalty to the RPG/Academy, and further understand that my effectiveness will be severely undermined if I take or have taken a position, either orally or in writing, directly or indirectly contrary to a position taken by the RPG/Academy, or if I have a relationship with a company, organization or enterprise that takes such a position. I am not presently aware of any such conflict, but recognize my duty to advise the RPG/Academy when and if such conflict should arise, or if my desire to take a position contrary to that of the RPG/Academy requires me to give up this position. I am listing below any companies, organizations or enterprises from which I receive compensation or with which I have an ongoing relationship.
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(c)If, as a part of my responsibilities, I am asked to perform services that I cannot, for any reason, perform in accordance with the standards of objectivity and credibility set forth here, I will immediately disclose to the RPG/Academy the source of my concern and request to be relieved from performing those particular services.
(d)If I am a reviewer and given a review assignment, I will advise the RPG/Academy immediately of any past or existing personal or professional relationships with any programs, works, persons or institutions related to the subject matter of the proposed review, as well as any other reasons that might keep me from conducting a fair and objective review of such subject matter.
(e)The following are the companies, organizations, or enterprises with which I have an ongoing relationship and which have some interest in the subject matter of the services I am asked to perform for the RPG/Academy:
Nature of relationshipEntity*
Employment______
Grants/Research Support______
Consultancy ______
Stockholder______
Honorarium______
Membership______
Other Financial/Material Support______
* (if None, please state “None”)
(f)I understand that the word “Conflict” in this statement is intended to mean any duality of interest that might be perceived as affecting my objectivity, integrity, impartiality, or loyalty to the RPG/Academy and its positions.
(g)I agree that this Conflict Disclosure Statement may be made public or shared with any RPG/Academy member or interested party, including attendees at conferences or symposiums at which I make a presentation.
Date: ______
(signature)
12/2012
SD