As a member of an APA Group of the American Psychological Association, I recognize that I owe duties of care and loyalty to the association. One aspect of fulfilling those duties is to avoid conflicts of interest in which my allegiance might be split between an association position or responsibility and some other professional, business, personal, or volunteer position, interest, or responsibility. I understand that disclosure of actual or perceived conflicts is intended to assist the APA in resolving conflicts of interest and the disclosing an actual or perceived conflict does not necessarily mean that a conflict of interest exists or that the conflict would unduly influence my actions or my ability to serve on an APA Group.

I have reviewed the APA Conflict of Interest Principles and Procedures and I am disclosing situations or areas in which it might even appear that I have conflicting duties to other entities. I invite any further review by the association of any aspects of these situations or areas that might be considered appropriate. Also, I will take other necessary steps, such as avoiding deliberation and resolution of certain issues if those steps are necessary to protect against liability to the association or to me arising from conflict of interest. I also recognize that conflicts may arise during the course of my tenure on the APA Group as agenda items come before the APA Group and that my personal circumstances may change over time. I will follow the APA Conflicts Policy in discharging my duties as a member of an APA Group.

You must answer all questions in this form. If you check yes to any question, you must provide details in the detail box. You will not be allowed to submit the form until all required fields have been answered.

I am a Representative of the following APA Group(s). “APA Group” means any APA task force, working group, board, committee, Board of Directors, or Council of Representatives. “APA Representative” means an individual serving on an APA Group.

AFFIRMATION
In consideration of my participation on an APA Group, I assign to the American Psychological Association all rights, including copyright, in any work products created in connection with my participation on the APA Group including but not limited to any publications or tools.

I acknowledge that my work for APA may involve confidential and/or privileged matters relating to internal business, legal or other issues that APA does not general disclose to the public and I agree to maintain these confidences during my service to the APA Group. I understand that this duty to keep these issues confidential continues indefinitely and does not end with my service to the APA Group.

I understand that I am expected to comply with the APA Conflicts Policy. To my knowledge and belief, I am in compliance with the APA Conflicts Policy, and have disclosed my affiliations. I understand that I have continuing responsibility to comply with the APA Conflicts Policy, and I will promptly disclose any affiliations required to be disclosed under the APA Conflicts Policy.