FY23-24 Annual Conflict of Interest Disclosure

All participants are advised of the FDA’s policy governing the disclosure of conflicts of interest. This policy is codified as Resolution 92H-022, as adopted by the House of Delegates on January 9, 1993, and reads as follows:

RESOLVED, that individuals serving as delegates, alternate delegates, officers, trustees, alternate trustees, council or committee members shall, at all times, exercise diligent care and unbiased judgment in assuring that no detriment to the FDA results from conflicts between their personal or business interests and those interests of the FDA.  And, be it further

RESOLVED, that agendas at all official meetings of FDA agencies contain a declaration of conflicts of interest at which time the presiding chairperson will ask all members of that body to express the conflict. And, be it  further

RESOLVED, that if an individual believes that he or she or a member of his or her immediate family may have a conflict of interest, whether personal or business in nature, which pertains to an ownership, contractual, financial or fiduciary interest, then the individual shall promptly and fully disclose the possible conflict to the president of the association and/or chairperson of the body for which the individual serves.  And, be it further

RESOLVED, that failure to disclose a material conflict of interest may be the basis for reconsideration of the question on a given issue according to parliamentary procedure at any further time.

FDA policy requires written conflict of interest disclosure.  You should have reviewed the conflict of interest policy and the disclosure form attached to your agenda. If you have already completed your form and turned it in, then it is not necessary for you to complete another. 

Companies with which the FDA has business relationships include, but are not necessarily limited to, the following:

Bank of America (Practice Solutions); Care Credit; US Bank (credit cards)(ADA); Serve-First Solutions; iCore Exchange; Mercedes-Benz (ADA); Abyde; TDSC.com, powered by Henry Schein, The Doctors Company.

If you or a member of your immediate family, directly or indirectly (such as through a trust) own stock in, or are in a position to be compensated by any of these companies, then write the company name down in the field at the bottom of this form and describe the nature of your relationship to the company. 

Lastly, please fill in your digital signature at the bottom of this form.  Thank you.

You are receiving this form because you are a Florida Dental Association representative or key employee.  You are being asked to disclose, in good faith, any financial interest (as defined in Article II of the attached Conflict of Interest Policy) you may have that creates an actual or potential conflict of interest in connection with your FDA leadership role.  You have a financial interest that should be disclosed on this form if you have, directly or indirectly, through business, investment, or family:

a. An ownership or investment interest in an entity with which the association has a business transaction or arrangement,

b. A compensation arrangement with an entity with which the association has a business transaction or arrangement, or

c. A potential ownership or investment interest in, or compensation arrangement with, an entity with which the association is negotiating a business transaction or arrangement.

For example, a doctor’s participating provider agreement with a managed care organization is not a potential conflict of interest because the FDA itself does no business with the managed care organization.  Also, travel reimbursement, honoraria and stipends paid according to the association’s annual budget are not potential conflicts of interest.  However, if you own an interest in or have a financial relationship with a business that, in turn, does business with the association, then you have a potential conflict of interest to disclose.

You should complete this form at your first FDA meeting of the fiscal year as directed at the meeting.  Your form will be reviewed by the FDA Board of Trustees.  If the board determines there is a potential conflict, they will contact you to discuss all material facts.  Your forms are otherwise kept confidential unless the FDA is required by law to disclose them, in which instance you will be notified.

By my signature below I acknowledge that I have read and understand the association’s conflict of interest policy; that I agree to comply with it on an on-going basis; and that I understand the association is a tax-exempt organization that must engage primarily in activities which accomplish one or more of its tax-exempt purposes and that it must also avoid transactions with leadership that result in inurement, impermissible private benefit or an excess-benefit transaction.

IMPORTANT: Listen to the instructions and listing of companies with which the FDA has a business relationship, and respond accordingly The link to instructions are in the body of the email that accomanies this form. The companies are also listed above in Part 2 of this form.

If you have a conflict or conflicts, state them in the next box. If you have no conflicts, skip to the signature box.