ICSM Committee Chair/Member
Disclosure Declaration Form

ICSM Committee Chair/Member Disclosure Declaration Form

The ISSM and ICSM must insure balance, independence, objectivity, and scientific rigor in all its activities. We require all individuals in a position to influence the direction of the ICSM to fill out the disclosure form below prior to the appointment to a chair or membership position within the ICSM. In order to ensure that our activities promote improvements or quality in healthcare and not a specific proprietary business interest or a commercial interest, we need to identify all conflicts of interest.

Individuals are required to disclose all financial and intellectual relationships with commercial interests (entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) in any amount as well as the nature of the relationship within the past 24 months.

Declaration of a conflict of interest does not necessarily preclude serving in a chair or membership role within ICSM. However, based on this disclosure information, ISSM/ICSM may disqualify any individual from planning, implementation and participation if a conflict of interest that may contribute to commercial bias is determined to exist and cannot be resolved. Therefore, a full and honest disclosure is encouraged. In accordance with the conflict of interest policy of ISSM, the undersigned confirms that all information below is complete and truthful.

Please fill out all fields and answer all the questions below prior to submitting this form.

ISSM COI Policy COI Policy

Have you reviewed and do you understand the ISSM COI Policy?

Personal Details
Conflict of Interest Read COI Policy

Do you have or have you had any financial or intellectual relationships with any (commercial) entities within the past 24 months, and could such affiliations potentially introduce bias into your role in ISSM/ICSM?

Please list each commercial entity with the type of relationship listed below. Please state whether the monetary value, or potential monetary value, of each relationship is worth more than 65,000 USD/year or equivalent in your local currency.

Commercial Entity 1
Commercial Entity 2
Commercial Entity 3
Commercial Entity 4
Commercial Entity 5
Commercial Entity 6
Commercial Entity 7
Commercial Entity 8
Commercial Entity 9
Commercial Entity 10

Will your position include the opportunity to promote or influence others to use specific products/services of the commercial entities you've listed above?

If the ISSM COI Committee believes there is a COI, might you agree to avoid promoting or intentionally influencing others about these goods or services in order to retain your position with ISSM?

Signature
Below is the signature pad. Use your mouse to draw your signature, then click the "Save" button to save the signature. If you make a mistake or want to sign again you can click the "Clear" button to clear the entire signature pad.
Developed by