IUGA Leadership and Management
Disclosure Declaration Form

IUGA Leadership and Management Disclosure Declaration Form

The IUGA 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 association to fill out the disclosure form below prior to the appointment to a leadership position within IUGA. 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 relevant 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 leadership role within IUGA. However, based on this disclosure information, IUGA 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 IUGA, 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.

Personal Details
Conflict of Interest Read COI Policy

Do you or any member of your immediate family or your business partner(s) have any relevant financial or 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 within the past 12 months?

Please list the commercial entities with the type of relationship listed below.

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

Signature
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