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 12 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.