ISGD Conflict of Interest Disclosure Statement

ISGD Conflict of Interest Policy Acknowledgment and Disclosure Statement

The purpose of this form is to disclose any actual or potential conflicts of interest, as defined in the International Society of Glomerular Disease's Conflict of Interest Policy. The information you provide will be used by the Board of Directors and Executive Director in order to fulfill ISGD's compliance obligations and ensure we are conducting our activities according to the highest ethical standards and applicable regulations.
By completing and submitting this form, you consent to ISGD's storage and use of your personal data, namely the information in your responses and your IP address, in order to meet its compliance and ethical obligations. If you have any concerns about this, please exit this page and instead contact the Executive Director or Board Secretary directly.*

Yes, I consent.
Please provide full and accurate information so that we can work with you to manage any potential conflicts of interest appropriately. Please also disclose any situation that could appear to be a conflict of interest, even if you believe it is not a true conflict of interest. Many potential conflicts can be managed, as long as they are disclosed appropriately.

If the Board has any questions or needs additional information, they will contact you to discuss further. Thank you!
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Country CodeArea CodePhone Number
I am (select all that apply):*

an ISGD Committee Memberan ISGD Director (Board Member)an ISGD EmployeeOther
Conflict of Interest Policy
The policy is also available to read on our website: https://www.is-gd.org/conflict-interest-policy
Please read the Conflict of Interest policy. You may download a copy using the download icon.
This Conflict-of-Interest Disclosure Statement has been prepared to carry out the policy and procedures set forth in the Conflict-of-Interest Policy (the "Policy") of the International Society of Glomerular Disease (“ISGD”). All terms used below are as defined in the Policy.

I, {name}, acknowledge that, in carrying out my duties for ISGD and/or ISGD’s Board or Pillar Committees, I am charged with a duty of fiduciary trust with respect to ISGD and/or am being asked to comply with the Provisions of the ISGD Conflict-of-Interest Policy. I acknowledge my responsibility to act in the course of my duties solely in the best interests of ISGD, without considering my interests or the interests of any other person or entity, and to refrain from taking part in any transaction or other activity if I do not believe in good faith I can act with undivided loyalty to ISGD.

I agree to comply with all the terms of the Policy, including the Standards of Conduct, and in furtherance of this compliance, I have listed below all interests and activities in which I or a member of my Family is engaged, which may constitute a Controlling Interest, Financial Interest, Ownership Interest, and/or Significant Relationship under the Policy. If neither I nor a member of my Family has a Controlling Interest, Financial Interest, Ownership Interest, or Significant Relationship to be listed, I have indicated this by selecting "none". This list is presented for disclosure to and evaluation by ISGD.
Disclosures

For definitions of terms, please refer to Article III of the Conflict of Interest Policy.
Controlling Interest

Do you have, or have you had within the past two years:
a CONTROLLING INTEREST in any organization that does business with ISGD (for example: corporate partners or sponsors, allied nonprofits, vendors, grant recipients)?*

Yes (myself)Yes (family members)None
a CONTROLLING INTEREST in any organization that is seeking to do business with ISGD?*

Yes (myself)Yes (family members)None
a CONTROLLING INTEREST in any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

Yes (myself)Yes (family members)None
Please provide details for all "yes" answers above. Specify the organization name, who is involved, and the nature of their involvement. You may also include any other relevant information.*
Example: My sister-in-law Maura Smith is the Chief Financial Officer of KidneyMeds Inc.
Financial Interest

Do you have, or have you had within the past two years:
a FINANCIAL INTEREST in any organization that does business with ISGD (for example: corporate partners or sponsors, allied nonprofits, vendors, grant recipients)?*

Yes (myself)Yes (family members)None
a FINANCIAL INTEREST in any organization that is seeking to do business with ISGD?*

Yes (myself)Yes (family members)None
a FINANCIAL INTEREST in any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

Yes (myself)Yes (family members)None
Please provide details for all "yes" answers above. Specify the organization name, who is involved, and the nature of their involvement. You may also include any other relevant information.*
Example: I receive consulting fees from Pharma Company X and I hold a 15% equity stake in Kidney Startup Y. I received a research grant from the Boston Nephrology League last year.
Ownership Interest

Do you have, or have you had within the past two years:
an OWNERSHIP INTEREST in any organization that does business with ISGD (for example: corporate partners or sponsors, vendors)?*

Yes (myself)Yes (family members)None
an OWNERSHIP INTEREST in any organization that is seeking to do business with ISGD?*

Yes (myself)Yes (family members)None
an OWNERSHIP INTEREST in any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

Yes (myself)Yes (family members)None
If "yes," please provide details. Specify the organization name, who is involved, and the nature of their involvement. You may also include any other relevant information.
Example: I have a 15% equity stake in Kidney Startup Y, where I was previously Chief Medical Officer. My daughter owns Seamless Conference Partners, an events planning firm that is bidding for a contract to assist with ISGD's next meeting.
Significant Relationships

Do you have, or have you had within the past two years:
a SIGNIFICANT RELATIONSHIP (including a contractual compensation relationship) with any organization that does business with ISGD (for example: corporate partners or sponsors, allied nonprofits, vendors, grant recipients)?*

Yes (myself)Yes (family members)None
a SIGNIFICANT RELATIONSHIP (including a contractual compensation relationship) with any organization that is seeking to do business with ISGD?*

Yes (myself)Yes (family members)None
a SIGNIFICANT RELATIONSHIP (including a contractual compensation relationship) with any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

Yes (myself)Yes (family members)None
If "yes," please provide details. Specify the organization name, who is involved, and the nature of their involvement. You may also include any other relevant information.
Example: I currently serve on the Board of Directors of the Galactic Kidney Society. My partner is an employee (research chemist) at BigPharma, Inc.
Discounts, Rebates, and Reduced Prices

Note: Please answer with reference to the past two years, as well as your current situation.
Please list any organizations from which you or your family members receive services or products at reduced prices, a discount or subject to rebates. Include descriptions of the price reductions, discounts, or rebates.
Example: I'm eligible for a 20% discount on BestHotels hotel rooms since my niece works for BestHotels.
Acknowledgement and Certification

Please read and sign.
Except as disclosed in this Disclosure Statement, I hereby certify that neither I nor any member of my Family has a Controlling Interest, Financial Interest, or Ownership Interest in, or Significant Relationship with, or receives services or products at reduced prices, discounts, or subject to rebates from an Organization which may, or which may appear to, conflict with the interests of ISGD. I further certify that, except as disclosed in this Disclosure Statement, I am not an officer, director, trustee, or employee of an Organization.

If a Controlling Interest, Financial Interest, Ownership Interest, or Significant Relationship arises after my submission of this Disclosure Statement, I agree to disclose the existence and nature of such Controlling Interest, Financial Interest, Ownership Interest, or Significant Relationship to the Board as soon as reasonably practicable. I hereby assume the duty of notifying ISGD’s Secretary, in writing or as otherwise specified by the Board of Directors, of any additions to, deletions from, or modifications to the information I have provided in this Disclosure Statement.

I acknowledge that I have received a copy of the Policy, that I have read and understand the Policy, and that I agree to comply with the Policy. I understand that ISGD is a tax-exempt organization and that, in order to maintain its federal tax-exemption, it must engage primarily in activities which accomplish one (1) or more of its tax-exempt purposes.

I hereby certify that all of the information I have supplied in this Disclosure Statement is true and correct to the best of my knowledge, information, and belief.
I agree that my electronic signature shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.*

I agree.
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ISGD Conflict of Interest Policy Acknowledgment and Disclosure Statement

Conflict of Interest Policy

Disclosures

Controlling Interest

Financial Interest

Ownership Interest

Significant Relationships

Discounts, Rebates, and Reduced Prices

Acknowledgement and Certification