Conflict of Interest Disclosure for AAGL Board Executive Committee

AAGL
There was an error on your page. Please correct any required fields and submit again. Go to the first error
Conflict of Interest Disclosure for
AAGL Board Executive Committee
 
 
This form must be completed by each member of the Executive Committee of the Board of Directors prior to participation on the Executive Committee of the AAGL Board of Directors or as requested.

In order for AAGL to further the educational, scientific and charitable purposes for which it was organized, and to maintain the reputation in which it is held by the public and the medical profession, it is important that AAGL decisions and actions not be influenced unduly by any special interests of individual members. The AAGL depends upon its leadership to shape its policies. The actions of those leaders in shaping such policies must not be inappropriately affected by outside influences. Therefore, it has always been, and continues to be, important to identify actual or potential conflicts of interest which might improperly affect AAGL activities and decisions. Accordingly, the Board of Directors has adopted this policy for the disclosure of conflicts of interest.
 
Dissociation Policy for the AAGL Board Executive Committee

In addition to being required to disclose all actual or potential conflicts of interest, the President, Vice President, Secretary-Treasurer, Immediate Past-President, Medical Director and Executive Director:

(1) May not during their terms of office hold an officer, director, managerial, employment or any other position, whether or not compensated, with any health-related business concern, defined as a for-profit entity that produces, markets, or distributes drugs, devices or services used by members of the AAGL in the treatment of patients ("health-related business concern").

(2) May not during their terms individually receive salaries, consulting fees, honorarium for advisory boards, royalties or any other form of compensation from a health-related business concern during their terms of office.

(3) May not during their terms participate as spokespersons for any such health-related business concern through an industry speakers bureau, advisory board, or otherwise, and may not present at educational programs sponsored, funded, managed or directed by such a health-related business concern. Individuals involved in editorial positions are acceptable.

Research or training grants by health-related business concerns to academic and private institutions with which these individuals are affiliated are not prohibited, but must be fully disclosed and in compliance with the individual's institutional conflict of interest policies.

Conflict of Interest is defined as an interest held by a member or a business associate or an immediate family member that could influence the member or be perceived as influencing the member to act contrary to the interests of the AAGL and for the member's own personal benefit or for the benefit of an immediate family member or business associate.

Family Member
For purposes of this disclosure an immediate family member is defined as a member's spouse, partner, children, parent(s), sibling(s), brother(s)-in-law and sister(s)-in-law.

Financial Relationships are defined as relationships in which the individual or family member as defined above benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest of ≥1% (e.g., stock, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits usually are associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected.

Health-Related Business Concern
Health-related business concern is defined as a for-profit entity that produces, markets, or distributes drugs, devices or services used by members of the AAGL in the treatment of patients ("health-related business concern").
I or my family members have been a director of, or have been employed by any legal firm, accounting firm, consulting firm, investment banking firm, commercial bank or other financial institution that has performed services for or sought significant business with the AAGL.
I or my family members have held an officer, director, managerial, employment or any other position, whether or not compensated, with any health-related business concern.
I or my family members have an ownership interest of ≥1% (e.g., stock, stock options or other ownership interest, excluding diversified mutual funds) in any one health-related business concern.
I or my family members have received greater than $1.00 during the last calendar year from any one health-related business concern, research or training grants and/or clinical trial.
A hospital, institution or organization has benefited or received greater than $1.00 in equipment, research or training grants and/or clinical trial(s) as a result of my relationship from any one health-related business concern.
If the answer to any question above is YES, please list organization(s) below:
If the answer to any question above is YES, please list organization(s) below:SourceRelationshipAmount
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I or my family members currently are or will be a director of, or will be employed by a legal firm, accounting firm, consulting firm, investment banking firm, commercial bank or other financial institution that has performed services for or sought significant business with the AAGL.
I or my family members currently hold or will hold an officer, director, managerial, employment or any other position, whether or not compensated, with any health-related business concern.
I or my family members currently have or will have an ownership interest of greater than 1% (e.g., stock, stock options or other ownership interest, excluding diversified mutual funds) in any one health-related business concern.
I or my family members expect to receive greater than $1.00 from any one health-related business concern, research or training grants and/or clinical trial.
A hospital, institution or organization will receive greater than $1.00 in equipment, research or training grants and/or clinical trial(s) as a result of my relationship from any one health-related business concern.
If the answer to any question above is YES, please list organization(s) below:
If the answer to any question above is YES, please list organization(s) below:SourceRelationshipAmount
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I currently participate as an officer, executive, board member, consultant, or in any other leadership role in any non-profit medical specialty societies.
If YES, please list organization(s) below:
If YES, please list organization(s) below:OrganizationRelationship
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
V. Speaking Engagements:
Personal Information