2027-2028 Conflict of Interest and Commitment Disclosure Form

SAEM Officers, Board Members, Editors-in-Chief, Deputy Editors, Committee Chairs, Task Force Chairs, Academy Executive Committee Members, Foundation Board of Trustees, and others acting on behalf of SAEM and the SAEM Foundation have a duty to the Society and its members, including the duties of loyalty, diligence, and confidentiality. This means that they must not put themselves in a position where their personal, professional, or fiduciary interests conflict with their duty to the Society. In accepting their office or position, individuals undertake to give the Society the benefit of their care, best judgment, and to exercise their powers solely in the Society’s best interest and not for their own personal interest or for the benefit of another organization.

Conflicts of interest arise when individuals in positions of responsibility have personal, professional, or fiduciary interests, obligations, or responsibilities that conflict with their duties to the Society. It is important to note that a conflict of interest depends on the situation, and not on the character or actions of the individual. For more detailed information, please refer to SAEM's Conflict of Interest and Commitment Policy or the SAEM Foundation Conflict of Interest Policy.

Please select the potential position(s) for the 2027-2028 year that require you to complete the Conflict of Interest and Commitment Disclosure Form.

Other (please specify)

Full Name

First NameLast Name

Work Email Address

example@example.com

Personal Email Address

example@example.com

Mobile Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please list your positions of employment, including the name of the institution/organization, title of your position, and brief description. If none, please enter N/A.

Please list any other Board positions you hold, including a brief description of the nature and purpose of the organization.(e.g. committee chair, journal editor, board member, academy executive committee, etc.).

Please list any committee, task force, and project involvement at the professional level (non-employer related and other than those within SAEM) including the position held, name of the parent organization, and a brief description of the nature and purpose of the committee, task force or project. If none, please enter N/A.

Please list any relationships in which you hold a position of responsibility or a substantial financial interest (other than a 1% or less interest in a publicly traded company) from which SAEM obtains or may obtain substantial amounts of goods or services, or which provides services that substantially compete with SAEM. If none, please enter N/A.

Please list any substantial financial interests or positions of responsibility in entities providing goods or services in support of the practice of emergency medicine (e.g., physician practice management company, billing company, physician placement company, book publisher, medical supply company, malpractice insurance company), other than owning less than a 1% interest in a publicly traded company. If none, please enter N/A.

Please list the activities, investments, or employment of all immediate family members, close relatives, spouse or partner who may be affiliated with an organization that has dealings or other substantial interests with SAEM, or provides goods or services in support of the practice of emergency medicine. Include their name, relationship to you, the position they hold, name of the organization, and a brief description of the nature of the relationship to SAEM or the practice of emergency medicine. If none, please enter N/A.

Please list any other interest you believe may create a conflict with the duty to the membership of SAEM or that may create the appearance of a conflict of interest. If none, please enter N/A.

I acknowledge my professional and fiduciary responsibility to the Society and pledge to avoid conflicts of interest or the appearance of conflicts of interest. I may have access to confidential information and pledge to protect the confidentiality of that information. I acknowledge that others may interpret my statements as speaking on behalf of SAEM even when I do not intend to do so. I shall clarify my position when speaking on my own behalf as opposed to speaking on behalf of SAEM.

I understand that signing my name below constitutes a legal signature confirming that I acknowledge and agree to the SAEM campaign guidelines listed above.

I understand that my electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Signature

Date