WACEP COI Form

Members of the Wisconsin Chapter, American College of Emergency Physicians Board of Directors who are in a position to control the actions of the Chapter or the content of an educational activity, are asked to disclose the existence of all relevant financial relationships they and/or their spouse/partner or immediate family members have with any commercial interest relevant to the WPA.

The intent of this disclosure is not to prevent members in having such organizational relationships, but rather, to provide other Executive Council members with information on which they can make their own decision about undue influence or conflict of interest.

Name*

First NameLast Name

E-mail*

Leadership Position*

eg - "Officer"; "Board Member"; "Councillor"

Do you or your spouse/partner/immediate familymembers have research activities sponsored by a commercial organization relevant to WACEP?*

YesNo

Are you or your spouse/partner/immediate familymembers currently serving as a paid consultant to a commercial organizationrelevant to WACEP?*

YesNo

Do you and/or your spouse/partner/immediate family members have significant investments in any financial or other business relationship with a commercial organization relevant to WACEP?*

YesNo

Are there any special relationships that youand/or your spouse/partner/immediate family members have with a commercialorganization or other disclosures that may be relevant to your participation inthe decision making of WACEP?*

YesNo

Of you answered Yes to any of the above questions, please provide details.

Resolution of Conflict of Interest:

I have read the disclosure information and answered the questions relative to WACEP. I attest that the relationship(s) I and/or my spouse/partner/immediate family members have with commercial organization(s) will not influence or bias my voting, planning, presentation, or evaluations regarding Board activities and that I will recuse myself from discussions and voting when appropriate. I understand that the information that I have disclosed will be shared with the Board.

Date*

e-Signature*

Conflict of Interest Form