Annual Conflict of Interest Form - Pennsylvania Academy of Family Physicians

Disclosure Year(Required)

Name(Required)

First Last Credentials

Phone(Required)

Country Phone Number

Email(Required)

List of Boards, Employers, and Offices

Control

List all organizations for which you or your spouse serve or have served as a member of the board of directors, advisory board, a commission, or in which you have or have held the position of an officer during the last three years.

Compensation Interest

List all of the companies, businesses and other organizations (including, but not limited to, the Academy) from which you receive directly more than $5,000 per year in compensation in the form of wages, salaries, bonuses, honoraria, or contractual payments for goods or services during the last three years.

Public Office

List any public office held by you in the last three years whether or not you were paid or are being paid for holding such office.

Other Disclosures and Known Potential Conflicts

For purposes of this Disclosure, a “Vendor” is defined as any business or organization that you are or become aware of that (i) provides goods or services to, or does any other business with, the Academy or which has sought to do so within the past three years or which seeks to do so in the future or (ii) that competes with the Academy, its products or services, or the products or services of any affiliates. With respect to Academy and the Vendors:

(A) Ownership(Required)

Do you have an ownership or investment interest in any entity (other than a 5% or less ownership in a publicly traded corporation which is a Vendor of the Academy?

Yes

Ownership Details(Required)

If yes, please specify.

(B) Compensation(Required)

Do you have a compensation arrangement (e.g., salary, consulting fee, honoraria, per diem, etc.) with the Academy or with any Vendor of the Academy?

Yes

Compensation Details(Required)

If yes, please specify.

Are you an uncompensated consultant, officer, Commission member, or board member of any Vendor of the Academy?

Yes

Uncompensated Position Details(Required)

If yes, please specify.

(D) Family Interest(Required)

Are you aware that a member of your family has an interest with a Vendor of the Academy of the nature described above in A through C?

Yes

Family Interest Details(Required)

If yes, please specify.

(E) Public Office(Required)

Do you hold a position in a public office or institution (other than the Academy), whether appointed, elected, or employed, which requires participation in matters involving the Academy?

Yes

Public Office Details(Required)

If yes, please specify.

(F) Other Interests(Required)

Do you have any other interests that may compete with or conflict with the interests of the Academy (e.g., a leadership position in a chapter or other entity with respect to activities that may be competitive with those of the Academy)?

Yes

Other Interests Details(Required)

If yes, please specify.

Acknowledgement Statement – Read and Acknowledge

I acknowledge that I have received a copy of the Conflict of Interest Policy (“Policy”) of the American Academy of Family Physicians (“Academy”), and that I have read, understand and agree to comply with the Policy. In accordance with the Policy, I hereby disclose and make a matter of record the potential conflicts of interest set forth on the Annual Disclosure Information Form attached as Attachment 1. I understand that it is my duty to disclose any of the following with respect to myself, and to update this disclosure as circumstances warrant: • An ownership or investment interest in any entity (other than a 5% or less ownership in a publicly-traded corporation) with which the Academy has a Transaction; • A compensation arrangement with the Academy or with any entity or individual with which the Academy has a Transaction; • A position in a public office or institution, whether appointed, elected or employed, which will require participation in matters involving the Academy; • A position as an uncompensated consultant, officer, Commission member or board member of any entity with which the Academy has a Transaction; or • Any other interest which may compete with or conflict with the interests of the Academy (e.g., a leadership position in a chapter or other entity with respect to activities that may be competitive with those of the Academy). • I become aware that a member of my Family has a Personal or Private Interest.

Electronic Signature(Required)

By entering your legal name here, you are affixing your electronic signature and confirming the answers provided on this form.

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