Annual Affirmation of Compliance and Disclosure

APSNA Annual Affirmation of Compliance and Disclosure

To be completed by Board Members, Committee Members, SIG Chairs, Others
Name*

First NameLast Name
Email*
example@example.com
Place of Employment:
Current Position/Title:
Daytime Phone Number

Area CodePhone Number
Curriculum Vitae/Resume:

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Prospective Role(s) in APSNA
Select the prospective role(s) that you may have in APSNA below: (check all that apply)*

Board MemberCommittee MemberSIG ChairEditorial BoardEditor in Chief (EIC)Other
I have received and carefully read the Conflict of Interest Policy for board members, staff, and volunteers of the American Pediatric Surgical Nurses Association (APSNA) and have considered not only the literal expression of the policy, but also its intent.

APSNA requires individuals subject to the Conflict of Interest Policy to disclose all relevant interests, including, but not limited to financial relationships with entities that could be affected financially by the activities of APSNA, such as Pharmaceutical, Biotech, Food & Nutrition, and Medical Devices and Equipment companies, or foundations, advocacy groups, or other organizations supported by entities that may have a financial stake in the outcome. Public funding sources, such as government agencies or academic institutions need not be disclosed. Time period for disclosure is within 5 years from when this form is completed.

Individuals subject to this policy need to disclose all relationships whereby they or immediate family member members have a financial interest/arrangement or affiliation with an entity that could potentially benefit financially from APSNA’s activities. An immediate family member is defined as a partner with whom participant has lived for ≥1 year in the same home, dependent or any other related person (by blood or marriage) with whom participant has lived for ≥1 year in the same home.

Financial links or affiliations with industry groups may include persons or entities:
- supplying goods and services to APSNA.
- from whom APSNA leases property and equipment.
- with whom APSNA is dealing or planning to deal in connection with the gift, purchase or sale of real estate, securities, other property or services.
- that provide philanthropy or other support to APSNA.
- which may affect the operations of APSNA.
Conflicts of Interest arise when a Board member or his/her immediate family has either - 1) a significant personal financial interest in, or business relationship with, an entity that may be affected by the outcome of APSNA, Inc. business with which the board member will become or is involved, e.g., the Board Member’s husband owns a medical quality assurance consulting firm and the Board Member is asked to make a decision about NDNQI that may affect her husband’s business; or 2) a significant individual professional benefit that may arise through any APSNA program/committee with which the individual will become or is involved, e.g., a university professor who is seeking a research grant to investigate ways to reduce pediatric surgical complications and will be making decisions about whether that same topic will be funded as an APSNA priority.

Significant Financial Interests are anything of monetary value from a business entity including salary, payments for service, consulting fees, honoraria, equity ownership (stocks, options, notes, etc.) and royalty-bearing intellectual property rights (patents, copyrights, trademarks). Income from an entity or equity in an entity must be aggregated for the board member, board member’s spouse or significant other, or dependent children. This includes the individual's place of employment.
Financial Relationships

Please indicate below whether or not you have any relationships to disclose. Please disclose all relationships whereby you or immediate family member(s) have a financial interest/ arrangement or affiliation with an entity that could potentially benefit financially from APSNA’s activities or that could/may have an impact on your service to APSNA in a leadership role.
Relationships to Disclose? - Personal

I/my immediate family members, DO NOT, to the best of my knowledge, have a significant personal financial interest, business relationship with an entity, or any other relationship(s) that may be seen as competing with the interests of APSNA or that may be affected by the work done by APSNA, Inc.I/my immediate family, DO HAVE personal financial interest, business relationship(s) with an entity, or other relationship(s) that may be seen as competing with the interests of APSNA or that may be affected by the work done by APSNA, Inc. to disclose.
Instructions - for each relationship, enter the following information into the table below:

Relationships to Disclose? - Professional

I/my immediate family, DO NOT HAVE a significant individual professional benefit that may arise through my involvement/service on any APSNA program/committee or word done by APSNA, Inc.I/my immediate family, DO HAVE a significant individual professional benefit that may arise through my involvement/service on any APSNA program/committee or word done by APSNA, Inc., to disclose.
Instructions - for each relationship, enter the following information into the table below:

By signing this affirmation of compliance, I hereby affirm that I understand and agree to comply with the Conflict of Interest Policy. I further understand that APSNA is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes.

If any situation should arise in the future which I think may involve me in a conflict of interest, I will promptly and fully disclose the circumstances to the President of APSNA, Inc. or to the VTL Solutions Chief Executive Officer, as applicable.
II further attest that the information provided in this affirmation is true and correct to the best of my knowledge, information, and belief, as of the date of submission (Signature)*

Clear
Should be Empty:

	Name of the Company/Person (full name not acronym)	Nature of the Relationship	Time Frame (e.g. January 2024-January 2027)	Has the Relationship Ended?
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	Company/Employer/Source/Board (full name not acronym)	Nature of the Relationship	Time Frame/Period of Employment (e.g. January 2024-January 2027)
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APSNA Annual Affirmation of Compliance and Disclosure

Prospective Role(s) in APSNA

Financial Relationships

Instructions - for each relationship, enter the following information into the table below:

Instructions - for each relationship, enter the following information into the table below: